T
D
I
EXAS
EPARTMENT OF
NSURANCE
Financial Regulation Division, Agent and Adjuster Licensing Office (107-1A)
(1
333 Guadalupe, Austin, Texas 78701 PO Box 12069, Austin, Texas 78711-2069
(512) 676-6500 │ F: (512) 490-1052 │ (866) 554-4926 │ TDI.texas.gov │ @TexasTDI
Biographical Form and Certification of License Qualification Following a Change of Control
This form must be completed to identify changes to control of a licensed insurance agency as required by Texas Insurance Code
§4001.252-4001.253. Use this form to report new individuals to be associated with a currently licensed insurance agency, individuals to be
disassociated from a currently licensed insurance agency, and/or changes to individuals or entities that control a licensed insurance
agency. This form also shall be used to certify that the agency satisfies the requirements for the issuance of the license it holds
immediately following the disclosed changes. All words and terms used in this form shall have the same meaning as defined in Texas
Insurance Code §4001.003.
NAME OF TDI LICENSED ENTITY
TDI ENTITY LICENSE NUMBER
□
This is Texas resident entity- Fingerprints are required for each individual listed on biographical application
□
This is a non-resident entity- Currently licensed in home state (home state is:___________).
OFFICIAL MAILING ADDRESS: This is the official address for all notifications from the department including renewal notice, delivery of
.
original and renewed license, service of process and all correspondence from the department
_____________________________________________________________________________________________________________
STREET, PHYSICAL LOCATION, ROUTE OR P.O BOX NUMBER
___________________________________________________________________________________________________________________________________________
CITY
STATE / ZIP CODE
BUSINESS ADDRESS: This address is the physical location of an agency's office. This is for reference purposes only, and will not be
used for official correspondence from this department.
_____________________________________________________________________________________________________________
PHYSICAL LOCATION
___________________________________________________________________________________________________________________________________________
CITY
STATE / ZIP CODE
Part 1 – Association of Individuals
Fully identify all new executive officers, directors, or partners of the agency who administer the agency's insurance operations in Texas
and all new individuals in control of 10% or more of the agency's voting stock. Attach additional pages as necessary. Fingerprints are
required for each individual listed, unless the individual has previously submitted fingerprints to the Texas Department of Insurance or one
of the exceptions listed below is met. (Check the appropriate box for each individual.) Disclosure of social security numbers is required by
Texas Family Code §231.302.
INDIVIDUAL’S LEGAL NAME
TITLE
SOCIAL SECURITY NUMBER
DATE OF BIRTH
MAILING ADDRESS
CITY
STATE / ZIP CODE
Resident
Non-Resident
□
Fingerprint / L1 enrollment Services receipt attached.
□
Individual has an active TDI license number
.
□
Fingerprints previously submitted (date
).
□
The above entity and/or the individual is currently licensed in resident state with a license similar to the license applied
for on this application
INDIVIDUAL’S LEGAL NAME
TITLE
SOCIAL SECURITY NUMBER
DATE OF BIRTH
MAILING ADDRESS
CITY
STATE / ZIP CODE
FIN531 Rev. 01/15
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