Hawaii Application For Individual Or Legal Entity Life Settlement Broker Or Provider Insurance License Form
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1
2Hawaii Application for Individual or Legal Entity
Print Form
Life Settlement Broker or Provider Insurance License
(Please Print or Type)
Check appropriate box for the Life Settlement license being applied for:
Provider License (resident; individual)
Broker License (resident; individual)
Provider License (non-resident; individual)
Broker License (non-resident; individual)
Provider License (resident; legal entity)
Broker License (resident; legal entity)
Provider License (non-resident; legal entity)
Broker License (non-resident; legal entity)
Current Hawaii life producer license number:
Date of Expiration:
LEGAL ENTITY APPLICANT
1. Business Entity Name
2. Incorporation/Formation Date (month/day/year) 3. FEIN
4. List any other assumed, fictions, alias or trade names under which you are doing business or intend to do business 5. State of Domicile
6. Country of Domocile
7. Business Address
8. City
9. State
10. Zip Code
11. Foreign Country
12. Business Phone
13. Fax
14. Business Web Site Address
15. Business E-Mail Address
16. Mailing Address or P.O. Box
17. City
18. State
19. Zip Code
20. Foreign Country
INDIVIDUAL APPLICANT
21. Social Security Number
22. If assigned, National Producer Number (NPN)
23. Last Name
JR./SR. etc
24. First Name
25. Middle Name
26. Date of Birth (month/day/year)
27. Residence/Home Address (Physical Street)
28. City
29. State
30. Zip Code
31. Foreign Country
32. Home Phone
33. Gender (Check One)
34. Are you a Citizen of the United States? (Check One)
Male
Female
Yes
No
(If No, of which country are you a citizen?)
(If No, you must supply proof of eligibility to work in the U.S)
35. Business Entity Name
36. Business Address (Physical Street)
37. City
38. State
39. Zip Code
40. Foreign Country
41. Business Phone
42. Business Fax
43. Business E-Mail Address
44. Business Web Site Address
45. Mailing Address or P.O. Box
46. City
47. State
48. Zip Code
49. Foreign Country
50. a. List any other assumed, fictitious, alias, maiden or trade names which you have used in the past.
b. List any trade names under which you are currently doing business or intend to do business.
(Continue on next page)
DO NOT WRITE IN THIS BOX - For State Use Only
Entity ID:
PDB
C&E
CHR $
License #:
CJIS
Health
I30 $
Eff Date:
Log
Legal
I08 $
Ext. Date:
$
(LSB/LSP Rev. July 20, 2012)
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Parent category: Legal