FORM L-191
Renewing the insurance license of an individual
For a license that expires on or before June 30, 2013
*Note: Application forms and instructions are subject to change without notice. Current versions of forms and instructions
are available from the PRODUCERS page of the Department’s Internet web site (www.azinsurance.gov).
TIME SENSITIVE MATERIALS!!!
If the Department of Insurance does not
receive your COMPLETE renewal application
prior to your license expiration, your license
will expire (you will be prohibited from
engaging in insurance business), you will be
subject to a late renewal fee, and you may be
subject to additional license requirements.
Carefully read instructions. Licensing laws regularly change. Instructions may describe additional
forms or documents you need to submit. If your application is incomplete, the application will be returned
as deficient. If the Insurance Licensing Section does not receive your complete application and fees by
or before your license expiration date, you shall lose the authority to transact insurance and you will be
required to pay a $100 late renewal fee to renew your license.
Submit your renewal application early. You can renew a license up to 90 days before it expires.
Submit your renewal application and fee using one of the following methods
Electronically using the Insurance Professional License Update System (“IPLUS”), at
iplus.azinsurance.gov.
Electronically using www.nipr.com
On paper using Form L-191
If renewing using Form L-191, make sure you submit all parts of the application. Form L-191
consists of two parts for non-residents and three parts for Arizona residents. All applicants (residents and
nonresidents) must complete Part I and Part II. Arizona-resident licensees must also complete Part III.
Clearly print in ink or type all information and carefully review your application before submitting it.
If submitting Form L-191 or an application printed from IPLUS, make sure to sign and date the applicant
certification section.
Retain these instructions for your records. Do not submit this instruction booklet with your application.
If renewing using a paper application, organize materials before submitting them, as follows:
Remove any stubs from the money order or check with which you are paying your license fee.
To the front of the application form, staple your payment, made payable to Insurance Licensing
Section, and send to
Insurance Licensing Section, 2910 N. 44th St # 210, Phoenix, Arizona 85018-7269
Page 1 of 4
Instructions for Form L-191, Eff. 07/2012
CONTINUING EDUCATION. If you are an Arizona resident who holds an insurance license other than as a
bail bond agent or adjuster, you must complete 40 hours of insurance continuing education if you held a
nonresident license in at least one other state at any time during the term of your expiring license. Part III
of the application will tell you whether you need to complete insurance CE.
ADDRESS/PHONE CHANGES. You must report name and address changes within 30 calendar days of the
change. Report address and phone number changes by using IPLUS (http://iplus.azinsurance.gov).
LICENSE CERTIFICATES. The Department does not print license certificates. If you submit a paper renewal
application, we will provide you a notice when your renewal has been processed. If you use IPLUS to renew
your license, the confirmation screen at the end of the process tells you that your renewal application was
successful. At any time, use the “License Search” feature on the Department’s web site to view or print out
your license.
ON-THE-SPOT SERVICE. In a hurry for your license? We can review a license application hand delivered to
the Insurance Department “on the spot,” while you wait. Many (but not all) applicants are able to obtain their
license before they leave our office. The last week of the month is especially busy, so bring us your
application toward the beginning of the month. On-the-spot service is available as follows:
Hours: Mondays through Fridays between 8 AM and 4 PM (except state-observed holidays)
Office Location: 2910 North 44th Street, Suite 210, Phoenix 85018-7269
LICENSING AND RENEWAL FORMS are available
from the Department’s “PRODUCERS” Internet web page at www.azinsurance.gov,
in person from the office during “on-the-spot service” hours – see above.
PART I
SECTION A:
o
If you are applying to renew Variable Life and Variable Annuities Producer authority, enter your
CRD number issued by the Financial Industry Regulatory Authority (“FINRA”) in the box provided in
SECTION A. FINRA records must show that you have an active registration with a broker-dealer.
o
Your business address MUST be the physical street address accessible to the public where you
transact insurance (not a post office box or postal mail box). If you conduct business from your home,
enter the address of your home in this section.
SECTION B: Enter the location or post office box where you want license-related correspondence sent, if
different than address in Section A. If the address belongs to a business, include the full business name.
Additionally, you may include your fax number and/or e-mail address to help us correspond with you.
SECTION C:
You cannot add lines of authority to your license using this application (see Form L-169).
If you surrender license authority, you will not be able to reapply for the line of authority for one year.
ARS 20-289(F).
If you do not qualify to renew a line of authority, you must remove it from your license and reapply for
the authority when you qualify (using Form L-169).
Page 2 of 4
Instructions for Form L-191, Eff. 07/2012
SECTION D: Make sure your application is accompanied by the correct amount of fees. Fees are nonrefundable (ARS § 20-167).
License Fees.
o
Include $1,120 in your payment if the license contains either the Surplus Lines Broker authority or
Mexican Insurance Surplus Lines Broker authority (because you need to pay $1,000 for the Surplus
Lines Broker license plus $120 for all other license authority); OR
o
Include $120 in your payment (regardless of the number of lines of authority on your license) if you
are not a Surplus Lines Broker or Mexican Insurance Surplus Lines Broker.
Late Renewal Fee. Include $100 in your payment to renew your license after the license expires for up
to one year after it has expired. You cannot conduct business under an expired license. To late renew
a license, the Department must receive within one year after the expiration date of the license,
o
a complete application and any other required documents
o
the nonrefundable license fee (described in Section D of the application), and
o
the $100 late renewal fee required by A.R.S. § 20-289(E).
If we receive your renewal application more than one year after your license expires, the application will be
rejected and you will need to submit an application for a new license and fulfill any examination, licensing
eligibility and fingerprinting requirements.
SECTION E must contain the physical street address of your residence (a P O Box or PMB is
unacceptable).
PART II: If you answered “YES” to any question in PART II, you are required to submit:
A SIGNED statement describing, in detail, all incidents including the names, dates and locations involved,
the names and localities of any courts and/or administrative agencies involved, and the disposition or
current status of each matter; AND
Copies of any and all indictments, complaints, plea agreements, orders of conviction, notices of hearing or
trial, sentencing orders, suspension/revocation orders and any other information that relates to each
matter. If copies are not available, you must provide as a part of this application a letter from the clerk of
the pertinent court or the official involved stating the records are not available and the reason.
PART III (For Arizona-resident Producers Only)
Your responses to questions in Section A of PART III will indicate whether you need to complete Arizonaapproved insurance continuing education (“CE”) courses. Nonresident licensees are NOT required to complete
Arizona-approved insurance CE courses. If your responses to Section A of PART III show you are required to
complete CE, you must submit a printout of your transcript from www.prometric.com OR you must submit
Arizona-approved Certificates of Completion (including the Arizona state seal) with your license application
demonstrating that you completed the required hours of continuing education.
Page 3 of 4
Instructions for Form L-191, Eff. 07/2012
ADDITIONAL APPLICATION REQUIREMENTS
NON-RESIDENT APPLICANTS
We will use the Producer Database (PDB) maintained by the National Insurance Producer Registry to
determine whether you are licensed in good standing in your home state. We will only require you to
submit a certification letter if we are unable to verify your home-state license status.
ASSUMED NAME (OR D.B.A.). In accordance with A.R.S. § 20-297, a licensee cannot use a name in
insurance business matters other than the true name unless approved by this office. Use Form L-193 to “file”
the name. To legally reserve the name, you may “register” the name by contacting the Arizona Secretary of
State’s Office. Call (602) 542-6187 for information about applying for a “Trade Name Certificate.”
MANAGING GENERAL AGENTS. Complete Form L-106 and have Form L-107 completed by an official of
the insurance company with which you have a contract. Submit both forms with your application.
RISK MANAGEMENT CONSULTANTS. Include a letter from the political subdivision (city/town/county)
authorizing you to serve as their Risk Management Consultant.
Organize your application materials and fee payment in the manner described on the cover and send
(without this instruction booklet) to the following address:
INSURANCE LICENSING SECTION, 2910 N 44TH ST # 210, PHOENIX, AZ 85018-7269
The Department Of Insurance is an Equal Employment Opportunity agency that complies with the Americans with Disabilities Act ("ADA") of 1990.
Persons with disabilities may request reasonable accommodation by contacting out ADA Coordinator at (602) 364-3471.
Page 4 of 4
Instructions for Form L-191, Eff. 07/2012
TO RENEW LICENSES expiring on or before 6/30/2013
Arizona Department Of Insurance
INSURANCE LICENSE RENEWAL APPLICATION: PART I
FORM L-191
1.
PLEASE READ THE ENCLOSED INSTRUCTION BOOKLET. Incomplete or illegible applications will be returned and a late fee may be incurred.
2.
MAKE SURE YOUR APPLICATION IS COMPLETE. Complete PARTS I and II (and PART III if you are an Arizona resident, excluding adjusters
and bail bond agents) and other requirements specified in the instruction booklet. An application that fails to meet renewal requirements will be
returned and you may be subject to a late renewal fee.
3.
Address the envelope containing application materials and fees EXACTLY AS FOLLOWS:
th
INSURANCE LICENSING SECTION, 2910 N. 44 Street # 210, Phoenix, AZ 85018-7269
SECTION A
Business
Information
You must provide a
physical street
address in Section A.
SECTION B
Mailing Address
(optional, if left blank,
address in Section A
will be used for
mailing purposes)
AZ Insurance License Number
Applicant Last Name
FINRA CRD Number (Variable Life/Annuity Producers)
Jr./Sr./II/III, etc.
Applicant FULL First Name
Physical Street Address of Your Business
State
City
Zip Code
Business Name (If the mailing address belongs to a business, enter the name of
the business here; otherwise, leave blank)
Mailing Street Address (may be either a street address or post office box)
City
State
Zip Code
E-mail Address
SECTION C
Renewal
Applicant FULL Middle Name
Check here
Business Area Code and Phone Number:
Any business entity you name in
Section A or B must be separately
licensed pursuant to A.R.S. § 20-285(D)
if it participates in the sale, solicitation
or negotiation of insurance. A.R.S. §§
20-282 and 20-298.
Fax Number
to renew all lines of authority on the license (and proceed to SECTION D) OR
Check here
to remove one or more lines of authority from the license. In the appropriate box below,
identify the line(s) of authority for which you do not qualify or that you want to surrender.
In this box, list the line(s) of authority for which you do not qualify:
In this box, list the line(s) of authority you want to surrender (for which you cannot reapply for one year):
SECTION D
Renewal fees for
licenses expiring
on or before
6/30/2013
Fees are nonrefundable per ARS § 20-167.
The fee to renew a license that does not contain Surplus Lines Broker or Mexican Insurance Surplus Lines
Broker is $120* (regardless of the number of lines of authority on the license).
The fee to renew a license that contains Surplus Lines Broker or Mexican Insurance Surplus Lines Broker
authority is $1,120* (regardless of the number of lines of authority on the license).
Make your payment, made out to “INSURANCE LICENSING SECTION,” by check, money order or (if paying
in person) by cash. We do not accept credit/debit cards.
*NOTE: If we do not RECEIVE your license fee and a complete application meeting all renewal
requirements on or before your license expiration date, you must add $100.00 to your payment
for the late renewal fee required by A.R.S. § 20-289(E).
SECTION E
Household
Address
Household Street Address (A physical street address is required)
City
State
Zip Code
Home Area Code and Phone #
THIS AREA FOR INSURANCE DEPARTMENT USE ONLY
TF#:__________________
_______________________
Renewed/Approved By
Page 1 of 3
_______________________
Late Renewal Date
57 Quad Other (120.00)
PDB Checked
59 Quad SLB (1000.00)
L-152 submitted
149 Late Renewal (100.00)
Form L-191, Eff. 07/2012
INSURANCE LICENSE RENEWAL APPLICATION: PART II
ADDITIONAL INFORMATION: Carefully read and respond to each of the following questions. You should provide a
“YES” answer even if you believe an incident has been cleared from your record. Willful misrepresentation of any
fact required to be disclosed in any application or accompanying statement is a violation of law and a ground to take
administrative action against you, including the denial your renewal application.
For the purposes of this application, "convicted" includes, but is not limited to, having been found guilty by
judge or jury or pled guilty or no contest to any felony charge. A "No" response is incorrect if applicant has had
any conviction dismissed, vacated, expunged, pardoned, appealed, set aside or reversed, etc., or had its civil
rights restored, had a plea withdrawn or has been given probation, a suspended sentence or a fine, or
successfully completed a diversion program.
NOTE: ADDITIONAL INFORMATION IS REQUIRED if you respond “YES” to any of the following. Please see the
instructions.
A
Have you had any professional, vocational, business license or certification refused, denied,
suspended, revoked or restricted, OR a fine/assessment/forfeiture, consent order,
administrative action etc imposed by any public authority that has not been previously
disclosed in a written format by you to this agency?
B. Have you ever withdrawn any application or surrendered any license to avoid any
disciplinary action or the denial of a license that has not been previously disclosed in a
written format by you to this agency?
Yes
No
Yes
No
C. Have you been convicted or found guilty of, have you had a judgment made against you for, or have you admitted
to,
any of the following that has not been previously disclosed in a written format by you to this agency:
1. A felony (of any kind)? ...........................................................................................................
Yes
No
2. Obtaining or attempting to obtain any type of license through misrepresentation or
fraud?.....................................................................................................................................
Yes
No
3. Forging another's name to any document related to an insurance transaction? ..................
Yes
No
4. Withholding, misappropriating, converting or stealing money or property? ..........................
Yes
No
5. Committing an insurance unfair trade practice or fraud? ......................................................
Yes
No
6. Using fraudulent, coercive or dishonest business practices including forgery with intent
to defraud?.............................................................................................................................
Yes
No
7. Conducting business in an incompetent, untrustworthy or financially irresponsible
manner?.................................................................................................................................
Yes
No
8. Transacting, or helping someone else transact, insurance without the required license
authority? ...............................................................................................................................
Yes
No
9. Intentionally misrepresenting the terms of an actual or proposed insurance contract or
application for insurance?......................................................................................................
Yes
No
D. Is any case currently pending against you in any jurisdiction accusing you of any issue listed
in Question C?..............................................................................................................................
Yes
No
E. If you are not applying for a bail bond agent license, answer “Not applicable.”
Otherwise, if you are renewing a bail bond agent license, have you EVER been convicted in
any jurisdiction of any crime (felony, open-ended or misdemeanor) that involved carrying,
illegally using or possessing a deadly weapon or dangerous instrument that has not been
previously disclosed in a written format by you to this agency? ...................................................
Not applicable
Yes
No
APPLICANT CERTIFICATION
By my signature below, I hereby certify that the information recorded on all parts of this application and on all attachments
and enclosures herewith, is true and correct to the best of my knowledge
___________________________________________________________
Page 2 of 3
_____________________
Form L-191, Eff. 07/2012
Applicant’s Signature
Date
INSURANCE LICENSE RENEWAL APPLICATION: PART III
(Supplement for Arizona Residents)
SECTION A: INSURANCE CONTINUING EDUCATION
Must be completed by all Arizona resident applicants
The following questions will help determine whether you need to submit proof of satisfying the Arizona Continuing Education
requirements with your renewal application. If you are required to complete Arizona-approved CE, you must submit a
transcript of your CE credits from www.prometric.com OR ORIGINALS of the CE Certificates of Completion (Arizona State
Seal and Bar Code must be on the certificates) and you must retain copies until the second renewal date after the period for
which the CE credits were earned (A.R.S. § 20-2903(A)). You may wish to review continuing education requirements
provided on the “PRODUCERS” page of the Department’s web site (www.azinsurance.gov).
1. Are you an Arizona resident?
Yes
No
If Yes, please proceed to question 2 in this section.
If No, you DO NOT need to complete Arizona-approved CE courses and you should skip the remaining questions in
this section (Part III)
2. Have you held an Arizona insurance license for more than one year?
No
If No, you DO NOT need to complete Arizona-approved CE and you should skip the remaining questions in this
section (Part III)
3. In Arizona, do you only hold a license as an adjuster or bail bond agent?
Yes
If Yes, please proceed to question 3 in this section.
Yes
No
If No (you hold another type of authority on your license), please proceed to question 4 in this section.
If Yes (you are only an adjuster or bail bond agent), you DO NOT need to complete Arizona-approved CE and you
should not answer Question 4 in this section (Part III).
4. At any time during the term of your expiring Arizona insurance license, were you licensed to transact insurance in any
other state?
Yes
No
If No, you DO NOT need to complete Arizona-approved CE.
If Yes, you need to complete CE.
Page 3 of 3
Form L-191, Eff. 07/2012
