Revised Resident Agent Licensing Application

INFORMATIONAL LETTER NO. 105 June 1997 TO: ALL INSURANCE COMPANIES LICENSED TO TRANSACT BUSINESS IN WEST VIRGINIA AND OTHER INTERESTED PARTIES RE: REVISED RESIDENT AGENT LICENSING APPLICATION The 1997 extraordinary session of the West Virginia Legislature passed House Bill 101 which amended and reenacted Chapter 48A of the West Virginia Code concerning Enforcement of Family Obligations. Effective July 1, 1997, 48A-5A-5(c) of the West Virginia Code requires that licensing authorities named in 48A-5A-2 shall require license applicants to certify certain information on the license application form concerning any child-support obligation the applicant may or may not have at the time of application. Contact Legislative Services, Room MB-27, State Capitol, Charleston WV 25305, to obtain a copy of House Bill 101. Enclosed is a copy of the West Virginia resident agent application form, LA-3(Rev. 6/97), which has been revised to include statements which must be answered by the applicant under penalty of false swearing. License applications received in this office on or after July 1, 1997, must be made on this revised version of the LA-3. Old versions of the LA-3 received on or after July 1, 1997, will be returned for re-submission on the revised form. West Virginia residents who are applying for a limited lines license to sell Credit Life/Credit Accident & Sickness products will continue, until further notice, to complete and submit Form CLA-1 (7/88) for licensing. However, the enclosed Affidavit concerning the applicants child-support obligation must be attached to, and will be considered a part of each application received in this office on or after July 1, 1997. Applications received without the attached Affidavit will be returned for re-submission with the completed Affidavit. Form CLA-1 is currently being revised to include a section containing the child-support questions and will be distributed for use, in lieu of the Affidavit, by all insurance companies in the very near future. The revised LA-3 and the Affidavit may be photocopied, using white paper, or a supply may be ordered by sending a written request including a large, self-addressed envelope to: WVIC -- Agents Licensing & Education, P0 Box 50541, Charleston WV 25305-0541. This Informational Letter, the revised LA-3, and the Affidavit should be immediately distributed to all individuals and offices within your organization who may be responsible for submitting agent licensing requests to this Department. Hanley C. Clark Insurance Commissioner LA-3 (Rev 1991) WEST VIRIGNIA INSURANCE COMMISSIONER APPLICATION FOR RESIDENT AGENTS LICENSE For Dept. Use Only License # _______________________ Eff. Date _______________________ Powers _______________________ CCAREFULLY READ REVERSE SIDE BEFORE COMPLETING FORM PART I – COMPLETED BY THE APPLICANT PRINT IN INK OR TYPE 1. FULL LEGAL NAME: _________________________________________________________________________________ FIRST MIDDLE LAST 2. SOCIAL SECURITY #:_______________________________ 3. DATE OF BIRTH: ______________________________ 4. RESIDENCE ADDRESS: ____________________________________________ Telephone #: ________________________ P.O. Box & Street, City, State, Zip 5. BUSINESS ADDRESS: ______________________________________________ Telephone #: _______________________ P.O. Box & Street, City, State, Zip 6. Are you currently licensed as a resident agent in West Virginia or any other state? 6. ___YES ___NO If YES: License # __________________ Date issued ______________ 7. Have you ever been previously licensed as a resident agent in West Virginia or any other State? 7.___YES ___NO If YES: State(s) of _________________ License # ____________ Date Issued ____________________ 8. Does applicant understand that it is illegal to pay any person any part of the premium or share commissions with a policyholder 8. ___YES ___NO or other person who is not a licensed individual? 9. Do you understand that residence address changes MUST be reported to this office within thirty (30) days? 9. ___YES ___ NO 10. Have you ever been penalized or fined, had a license denied, refused, suspended, or revoked by this Department or the 10. ___YES ___NO this Insurance Department or any other State? 11. Have you ever been charged by an insurance agency or company with financial irregularities, or are you 11.___YES ___NO indebted to any insurance company for any overdue and unpaid money? 12. Have you ever been indicted for, or convicted of, a felony or misdemeanor (exclude traffic violations) 12. ___YES___ NO NOTE: 'YES" responses to Questions 10, 11, and 12 must be explained by furnishing, IN WRITING, a signed, notarized statement, outlining IN DETAIL the complete facts of the matter. The statement must include ALL incidents and the dates, names, and nature of each offense; the name and locality of the court(s), if any, involved; the disposition of each matter; and, a CERTIFIED COPY of any legal record concerning each offense. West VirgInia Code 48A-5A-5(c) REQUIRES THE APPLICANT OT RESPOND TO EACH OF THE FOLLOWING STATEMENTS: 13. Do you have child support obligation? 13. ___YES___NO a. If YES, does the arrerage (amount owed) equal or exceed the amount of child support payable for six months? 13A.___YES___NO 14. Are you the subject of a child-support related subpoena or warrant? 14.___ YES___NO I HEREBY CERTIFY, UNDER PENALTY OF FALSE SWEARING, THAT THE INFORMATIONPROVIDED IN THIS APPLICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I FURTHER UNDERSTAND THAT MAKING FALSE STATEMENTS ON THIS APPLICATION MAY RESULT IN DISCIPLINARY ACTION INCLUDING, BUT NOT LIMITED TO, REVOCATION OR SUSPENSION OF THE LICENSE FOR WHICH I AM MAKING APPLICATION. 15. APPLICANT’S SIGNATURE: ___________________________________________________________ DATE: _____________________ 16. State ____________________________________________ . County of ______________________ The applicant, whose name appears signed to the writing above, after first being duly sworn by me, says that the above statements are true to the best of his/her knowledge and belief. Taken, sworn to and subscribed before me this ______ day of __________________ , 19 ____ SEAL Notary Public Signature: ________________________________________ My Commission Expires _____________________ *** PART II -- TO BE COMPLETED BY THE INSURANCE COMPANY ** __________________________________________________ COMPANY WV I.D. # (10 digits) 17. COMPANY NAME: ___________________________________________________________________________hereby appoints 18. AGENT’S NAME: _____________________________________________________________________________ as a Non-Resident Agent for: 19. ______ LIFE (includes Credit Life) ______ VARIABLE ANNUITY _____TITLE ______ACCIDENT & SICKNESS (includes Credit A&S) ______ PROPERTY-CASUALTY _____TICKET BAGGAGE Pursuant to WV Admin. Regulations – 114-2-2.1, the company has made an investigation as to the suitability of the appointee. Attached is $25.00 License Fee -- Check # _______________________________ Dated ________________ _____________________________________________ ____________________ (_______)__________________ Appointing Official Signature Date Phone Number LA-3 (Rev.6/97) WEST VIRGINIA INSURANCE COMMISSIONER Application For Resident Agent’s License Instructions PART I -- RESIDENT APPLICANTS INSTRUCTIONS: 1. Only legal residents of West Virginia may apply for a Resident Agents license. 2. To be used by Residents applying for a first-time license or amendment to an existing license. 3. Complete and sign Part I of the application before a Notary who must notarize your signature. 4. Attach documentation, as required, if response is "YES" to Questions 10, 11, and/or 12. 5. Address changes must be reported to Agents Licensing & Education with thirty (30) days. PART II-- INSURANCE COMPANY INSTRUCTIONS: 1. Complete Part II and sign by Appointing Official. 2. Incomplete and/or incorrect applications will be returned to the company for completion/correction. 3. The completed application must be accompanied by: a. ORIGINAL testing service score report. b. ORIGINAL Pre-Licensing Course Completion Certificate (Form PL789E). c. Clearance Letters, if applicant was licensed as a resident agent in any other state(s). d. Copy of NASD (Series 6 or Series 7) or SEC registration if applying for Variable Annuity. e. Documentation of responses to Questions 10, 11, and/or 12. f. License Fee: $25.00 Company check made payable to WEST VIRGINIA INSURANCE COMMISSIONER. g. elf-addressed return envelope (Acknowledgment will not be mailed unless envelope is provided) . Note: Item 3c -- Clearance letter(s) are not needed if applying to AMEND an existing agents license. Items 3a, 3b, & 3d -- Do not apply to Title or Ticket Baggage applicants. Send the completed application, license fee, and all required attachments to: WEST VIRGINIA INSURANCE COMMISSIONER Agents Licensing & Education PO Box 50541 Charleston, WV 25305-0541 Telephone (304) 348-0610 Overnight Mail Address: 1124 Smith St., Charleston WV 25301 FORM MAY BE PHOTOCOPIED USING WHITE PAPER COPY MUST BE LEGIBLE AFFIDAVIT To be completed and considered part of form CLA-1 (7/88), Application for Agent’s License, Limited to Credit Life/Credit Accident & Sickness insurance products West Virginia Code 48A-5A-5(c) requires the applicant to respond to each of the following statements: 1. Do you have a child support obligation? ___YES___NO If YES, does the arrearage (amount owed) equal or exceed the amount of a child support payable for six months? ___YES___NO 2. Are you the subject of a child support related subpoena or warrant? ___YES___NO I HEREBY CERTIFY, UNDER PENALTY OF FALSE SWEARING, THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I FURTHER UNDERSTAND THAT MAKING FALSE STATEMENTS ON THIS APPLICATION MAY RESULT IN DISCIPLINARY ACTION INCLUDING, BUT NOT LIMITED TO, REVOCATION OR SUSPENSION OF THE LICENSE FOR WHICH I AM MAKING APPLICATION. APPLICANT’S SIGNATURE:___________________________ DATE:____________ NOTARY SECTION: STATE OF ________________________, COUNTY OF ________________________ The applicant, whose name appears signed to the writing above, after first being duly sworn by me, says that the above statements are true to the best of his/her knowledge and belief. Taken, sworn to and subscribed before me this ________day of _____________, ______ NOTARY PUBLIC: __________________ My Commission Expires: _______________ (SEAL)