Insurance Licence Renewal

INSURANCE LICENCE RENEWAL

Applicant Information

Applicant Name:

Licence Number:    Date of Birth:

Primary Contact Phone:    Email:

Licence Details / Lines of Authority

Current Licence Expiration Date:

Select lines of authority to be renewed (check all that apply):

Life

Health

Property

Casualty

Personal Lines

Adjuster

Surplus Lines

Title

Other:

Continuing Education

I certify that I have satisfied continuing education requirements for the renewal period:

Yes    No

Background and Disclosures

Answer the following. If any answer is yes, provide full explanation in the space provided and attach supporting documentation.

1. Have you been convicted of a felony since your last renewal?    Yes    No

2. Have you had any insurance licence denied, suspended, revoked, or subject to disciplinary action?    Yes    No

3. Are there any unsatisfied judgments, regulatory fines, or unresolved consumer complaints against you?    Yes    No

4. Have you filed for bankruptcy since your last renewal?    Yes    No

Payment

Payment Method:    Check    Credit Card    Electronic Check

Attachments / Documentation Checklist

Continuing education certificates

Photographic identification (copy)

Proof of payment / receipt

Other supporting documentation (describe below)

Declarations and Certification

By signing below I certify, under penalty of perjury and pursuant to applicable licensing statutes and regulations, that the information provided on this Insurance Licence Renewal application is true, accurate and complete to the best of my knowledge. I further acknowledge and agree that:

1. I understand that providing false or misleading information, failing to disclose material facts, or withholding information required by law or regulation may result in denial, revocation, suspension or other disciplinary action against my licence and may subject me to civil or criminal penalties.

2. I authorize the licensing authority to verify any information contained in this application, including but not limited to criminal background, regulatory actions, financial records, and continuing education compliance. I consent to the release of such information by third parties as necessary to process this renewal.

3. I affirm that I will comply with all applicable statutes, rules, regulations, and conditions of licensure, and that I understand any changes in my legal name, address, business affiliation, or criminal/administrative status must be reported in accordance with licensing requirements.

4. I attest that all required continuing education documents and fees are submitted with this renewal or will be submitted as required by the licensing authority.

I declare under penalty of perjury that I have read and understand the foregoing certification and that the statements made in this application are true and correct.

Sign Now