Form L-176 - Application For A License For Firm Or Corporation (Page 2 of 2) in pdf

SECTION VI: ADDITIONAL INFORMATION

For the purposes of this application, “convicted” includes, but is not limited to, having been found guilty by judge or jury or pled guilty or no contest to any felony,

misdemeanor or open-ended offense. A “NO” response is incorrect if applicant has had any conviction dismissed, expunged, pardoned, appealed, set aside or reversed,

or if licensee had its civil rights restored, had a plea withdrawn or if applicant has been given probation, a suspended sentence, was issued a fine, successfully

completed a diversion program, etc.

If “YES” is answered, see Section VI, “COMPLETING THE APPLICATION”.

Has the applicant or any individual designated in the application as a principal or any individual who is to exercise the powers conferred

Yes

by the license been convicted of a felony?

Has the applicant or any individual designated in the application as a principal or any individual who is to exercise the powers conferred

Yes

by the license had any professional license, vocational license, business license or certification refused, denied, suspended, revoked

or restricted?

Has the applicant or any individual designated in the application as a principal or any individual who is to exercise the powers conferred

Yes

by the license withdrawn any application or surrendered any license to avoid any disciplinary action or the denial of a license?

Has the applicant or any individual designated in the application as a principal or any individual who is to exercise the powers conferred

by the license had any judgment, order or other determination issued or imposed in any criminal, civil, administrative or other judicial or

quasi-judicial proceeding of any kind in any jurisdiction based on any of the following:

1. Misappropriation, conversion or the withholding of moneys?

Yes

2. Incompetence or a source of injury and/or loss to anyone?

Yes

3. Dishonesty in business or financial matters?

Yes

4. Fraud or misrepresentation?

Yes

5. Any cause arising out of an insurance transaction?

Yes

Are any civil, administrative, other judicial or quasi-judicial proceedings of any kind, or any criminal proceedings in which an

indictment, criminal complaint or information has been issued naming the applicant or any individual designated in the application as a

principal or any individual who is to exercise the powers conferred by the license, as defendant, currently pending in any jurisdiction

based on any of the following:

1. Misappropriation, conversion or the withholding of moneys?

Yes

2. Incompetence or a source of injury and/or loss to anyone?

Yes

3. Dishonesty in business or financial matters?

Yes

4. Fraud or misrepresentation?

Yes

5. Any cause arising out of an insurance transaction?

Yes

If the applicant is applying for a license as a bail bond agent, has the applicant or any individual designated in

Not

Yes

the application as a principal, including any employee of the applicant, been convicted of theft?

applicable

Has the applicant or any individual designated in the application as a principal or any individual who is to exercise the powers conferred

Yes

by the license, had an agency contract terminated by an insurance company or managing general agent for any alleged cause?

Is the applicant or any individual designated in the application as principal or any individual who is to exercise the powers conferred by

Yes

the license presently indebted to any insurer or any insurance company or managing general agent?

Is/was applicant ever licensed to transact insurance in this state or any other state? If “yes”, list the states

Yes

__________________________________________________________________________________

AFFIDAVIT OF VERIFICATION (must be executed by two members, officers, directors, trustees or, if a limited liability company, managers)

STATE OF:

)

) ss.

COUNTY OF:

)

____________________________________________ and ______________________________________, being first duly sworn, depose and say: We are the

authorized individuals who represent the applicant named hereon which is organized under the laws of the State of Arizona or possesses official authority to do business

in Arizona. We have read the application and accompanying materials, and each statement, answer, attachment and enclosure provided in the application and

accompanying materials are true, complete and correct. We acknowledge that if there exists any fraud or misrepresentation in attempting to obtain any insurance license

in this State, the Director of Insurance may refuse to accept any application for a license. We understand that pursuant to A.R.S. § 20-304, application for and

acceptance of a nonresident license constitutes an irrevocable appointment of the Director of insurance as attorney of the licensee for the acceptance of service of

process issued in this state in any action or proceeding against the licensee arising out of such licensing or out of transactions under the license. Process service on the

director on behalf of a nonresident licensee constitutes service on the licensee as though the licensee were personally served with process in this state.

SUBSCRIBED AND SWORN TO before me this ______ day of _________________________, _________.

_________________________________

Notary Public

By:

______________________________________ ____________________________

Signature of Authorized Representative

Official Title

My Commission Expires______________

By:

______________________________________

____________________________

Signature of Authorized Representative