California Department of Insurance Application

Application to Renew Individual Insurance Adjuster (AJ) or Public Insurance Adjuster (PJ) License

State of California Department of Insurance
LIC 448-29C (Rev 3/2015)

Name:

License Expiration Date:

Insurance License Number: National Producer Number:

Current renewals can be renewed faster online at www.insurance.ca.gov, under Online Services.

Renewal Application Certifications

1. Have you been convicted of a crime which has not been previously reported to the California Department of Insurance? Yes No.

“Crime” includes a felony, a misdemeanor or a military offense. “Convicted” includes, but is not limited to, having been found guilty by a verdict of a judge or jury, having entered a plea of nolo contendere, no contest, having had any charge expunged, dismissed or plea withdrawn pursuant to Penal Code 1203.4, or having been given probation, a suspended sentence or a fine. You may exclude traffic citations and juvenile offenses tried in juvenile court. You should answer “yes” if you have been convicted of a felony or a misdemeanor including driving offenses such as, but not limited to, reckless driving, driving under the influence and driving with a suspended license, whether or not you spent any time in jail, and whether or not you believe the conviction has been removed from your record.

2. Have you been involved in any administrative disciplinary action which has not been previously reported to the California Department of Insurance? Yes No.

“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license. “Involved” also means having a license application denied or the act of withdrawing an application to avoid a denial, include any business so named because of your actions in your capacity as an owner, partner, officer, director, or member or manager of a Limited Liability Company. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.

Important Notice: If you have answered “Yes” to 1 or 2, attach a detailed statement, signed by you (original signature), of the events which led to the charges (dates and places). If the matter was heard in court, attach copies, Certified by the Court, of the Criminal Complaint and Minute Order showing the final plea, judgment and sentence.

Applicant’s Certifications:

I certify (or declare) under penalty of perjury, under the laws of the State of California, that I have read the forgoing renewal application and certifications and know the contents thereof and that each statement therein made is full, true and correct. Pursuant to Insurance Code Sections 1703 and 1733, I authorize disclosure to the Insurance Commissioner of all financial institution records of any fiduciary accounts for the duration of this license. I understand that any changes in background information (per CIC 1729.2) must be filed within 30 days or my license can be subjected to disciplinary action. I certify that I am in compliance with the background information reporting requirements of CIC 1729.2.

*If an active Insurance Adjuster qualification exists, submit with this application, the Qualified Manager list, the Branch Office list (if applicable), and a list of your employees acting as adjusters. Provide full names and social security numbers. Fees, all lists, and signed renewal application certification must be postmarked within 30 days after date shown. If postmarked after that date, the following delinquent fees are also due: Independent Adjuster $72. The application to renew an expired AJ license or branch office may be filed up to one year from the date your license expires.

**If an active Public Insurance Adjuster qualification exists, fees, and signed renewal certification and Branch Office Certificate (if applicable) must be postmarked within 30 days after date shown If postmarked after that date, the following delinquent fees are also due: Public Insurance Adjuster $62. The application to renew an expired PJ license or branch office certificate may be filed up to one year from the date your license expires.

Warning: The terms of this renewal may be limited by the Family Support Law, Welfare and Institution Code Section 11350.6

Section 31(e) of the California Business and Professional Code allows the State Board of Equalization and the Franchise Tax Board to share taxpayer information with the Department of Insurance. Applicants and licensees are required to pay all state tax obligations and failure to comply with this requirement may result in suspension of license(s) issued by the Department of Insurance.

Address changes must be filed online at www.insurance.ca.gov under Online Services.

For a change of name, attach a signed and dated statement requesting name change and attach copy of any name change document(s). You will be notified if there are any further requirements. For business entity name change questions contact our Adjuster Unit at 916-492-3085.

Make check payable to: California Department of Insurance, Mail to: P.O. Box 311, Sacramento, CA 95812-0311, Information: (916) 492-3085.