Fillable Form Il446-0153 - Resident Business Entity License printable pdf download

Illinois Department of Financial and Professional Regulation

Division of Insurance

320 W. Washington Street

Springfield, IL 62767-0001

Resident Business Entity License

License and Fee Information: License fee $150.00. Make check or money order payable to the

Director of Insurance.

Name of Business Entity

Tax #

Business address (Number, Street)

City, State, Zip

(Check one)

Telephone number of agency

Corporation

Partnership

Sole Proprietorship

Limited Liability Company

List the full name, social security number and signature of person(s) authorized to act on behalf of the business entity. The person(s) signing

this form shall be held responsible for compliance of the business entity with the Illinois Insurance Code and 50 Illinois Administrative Code.

The designated person(s) must be licensed as an insurance producer in Illinois and must be an OFFICER OR DIRECTOR of the agency.

Name

Social Security #

Signature

If a corporation, list all members holding 10% or more of the stock and the number of shares held by each.

Name

Yes

√

1. Has the business entity or any officer or director been convicted of a felony? If “yes,” attach certified copies of the

indictment, judgement, and sentencing order.

2. Has the business entity or any officer or director, within the past 12 months, been adjudged bankrupt and did the

bankruptcy include insurance fiduciary monies? If “yes,” enclose a copy of the order of bankruptcy, including a

complete list of creditors.

3. Has the business entity or any officer or director been refused a license to act as an insurance agent, broker, producer

or solicitor, or has a license to act as such ever been denied, suspended, revoked or surrendered for disciplinary

reasons in any state either as an individual or as a member of a business entity? If “yes,” attach a copy of the order

and other applicable documents.

4. Bond Requirement: “Brokering” is placing insurance business with insurers with which you do not have an agency

contract or placing it through other insurance producers. If you broker, you must maintain, in your possession, a

bond in favor of the people of Illinois in the amount of $2500 or 5% of the premiums brokered in the previous calendar

year, whichever is greater but not to exceed $50,000 total aggregate liability. A bond in the name of an Association

can meet your requirement; however, you are responsible for assuring the bond is in effect and is for the correct

amount. Your license can be revoked if you broker business and do not have the required bond. Do not send the

bond to the Division.

Important Notice: Disclosure of this information is required under the Illinois Revised Statutes’ insurance laws. Failure to provide this information will result in this

form not being processed. This form has been approved by the Forms Management Center.

Rev. 07/04

IL446–0153

Form Il446-0153 - Resident Business Entity License

Related Articles

Related forms

Related Categories