State Police Criminal Background Check for New Individual License applicants for Full Lines and Limited Lines of Authority

Arkansas Insurance Department Mike Huckabee Julie Benafield Bowman Governor Commissioner 1200 West Third Street, Little Rock, AR 72201-1904 · (501) 371-2600 · (501) 371-2618 fax · www.insurance.arkansas.gov Information (800) 282-9134 · Consumer Services (800) 852-5494 · Seniors (800) 224-6330 · Criminal Inv. (866) 660-0888 March 28, 2006 BULLETIN NO. 3-2006 TO: All Licensed Foreign and Domestic Insurers, Farmers’ Mutual Aid Associations, Hospital and Medical Service Corporations, Health Maintenance Organizations, Fraternal Benefit Societies, Insurer Trade Associations, Producer and Broker Trade Associations, Adjuster Trade Associations, Funeral Directors, Licensed Managing General Agents/Agencies, and Other Interested Parties. FROM: ARKANSAS INSURANCE DEPARTMENT SUBJECT: State Police Criminal Background Check for New Individual License applicants for Full Lines and Limited Lines of Authority Act 1697 of 2005, Ark. Code Ann. 23-64-506 (c), requires the Department to conduct a criminal background check on resident applicants, in order to verify the application information and to ensure that only applicants eligible by law to be producers, consultants, and adjusters are licensed. The Department’s background check on applicants does not reduce or remove the responsibility of the appointing Insurer to conduct an initial appointment investigation under Ark. Code Ann. 23-66-513. In order for the Department to perform a background check on all new resident applicants, both resident individuals who are applying to sit for an insurance exam and those resident individuals applying for a “limited line” license (not requiring an examination), the following must be provided: • All individuals must complete an Arkansas State Police Individual Record Check Form (ASP-122) using the applicant’s full legal name and attach it to the Department’s application for exam permit or limited lines license application. • The form must be signed and the signature notarized by an Arkansas Notary Public. • A legible photocopy of the applicant’s Arkansas drivers’ license or Arkansas identification card must also be attached to the ASP-122 form. • A separate check from the insurer or agency or a money order or cashier’s check made payable to the Arkansas Insurance Department in the amount of $20.00 must be attached to the form. • No personal check from the applicant or other individual will be accepted for this payment, nor can this payment be combined with any other Department fee. This new procedure is effective May 1, 2006 and all resident applications received on or after that date must have the completed ASP-122 form, fee, and legible driver’s license photocopy attached. If all documents are not included, the application paperwork will be immediately returned to the applicant unprocessed. A copy of form ASP-122 is attached to this bulletin. The ASP-122 application with application instructions can be found on the Department’s website at www.insurance.arkansas.gov under the License Division link. If you have any questions regarding this matter, please contact Fred Stiffler, Director of the License Division at (501) 371-2750 or fred.stiffler@arkansas.gov. _______________________________ ________March 28, 2006_________ JULIE BENAFIELD BOWMAN Date INSURANCE COMMISSIONER ARKANSAS STATE POLICE Identification Bureau Individual Record Check Form ASP-122 (Rev. 11/05) Full Name: ________________________________________________________/__________________ First Middle Last Name Maiden/Other Date of Birth: ____________________________ State of Birth: ___________Race: ____Sex: ____ (Month/Day/Year) Social Security #: ________________________________ Driver’s License #: __________________ State Mailing Address: ______________________________________________________________________ Street City State ZIP Daytime Phone #: (_____)____________________________ I GIVE MY CONSENT FOR THE ARKANSAS STATE POLICE TO CONDUCT A CRIMINAL RECORD SEARCH ON MYSELF AND RELEASE ANY RESULTS TO THE FOLLOWING PERSON OR ENTITY: Name: ________________________________________________________________________________ (First/MI/Last Name) or Full Name of Agency Mailing Address: ______________________________________________________________________ Street City State ZIP Signature: ______________________________________________________ Date: _______________ (First/MI/Last Name) (Month/Day/Year) (NO REQUEST WILL BE PROCESSED WITHOUT A NOTARIZED SIGNATURE) STATE OF _____________________________________ § COUNTY OF ____________________________________ Subscribed and sworn before me, a Notary Public, in and for the county and state aforesaid, this the ______________ day of ____________________, 20 ________________ . _________________________________ Notary Public □ 82001 Civil Record Check