Form Il446-0169 - Public Adjuster License Application-Pa-1
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1Illinois Department of Insurance
320 W. Washington Street
Springfield, IL 62767-0001
Public Adjuster License Application–PA–1
Instructions:
Fee Requirement: Attach a check or money order payable to the Director of Insurance as follows:
$30.00–License fee for one year.
Bond Requirement: All applications for public adjusters licenses must be accompanied by a surety bond in the amount of
$5,000.
The proper bond (Form PAB) must contain:
The name of the principal/licensee as it appears on the application.
The principal’s address as it appears on the application for license.
The surety company’s name and company number.
The bond number.
Original signature of the principal and the surety company’s officer or attorney-in-fact.
Name
Social Security #
Home address (number, street) (P.O. box number is not acceptable as residence address)
Apt. #
City
State
Zip Code
Date of Birth
Phone #
Yes
No
1. Have you, within the past three years, been found guilty of a felony? If “yes,” attach (1) a statement
from your probation officer; (2) certified copies of the indictment, judgement and sentencing order.
2. Have you, 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. Have you ever 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 firm? If “yes,” attach a copy of the
order and other applicable documents.
The undersigned declares under penalties of revocation or refusal of license that the statements made in this application are true, correct
and complete to the best of his/her knowledge and belief.
Signature
Date
Important Notice: Under the Illinois Revised Statutes’ insurance laws, disclosure of this information is voluntary; however, failure to comply may result in
this form not being processed. This form has been approved by the Forms Management Center.
IL446–0169
Printed on recycled paper.
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