Form L-169 - Application For An Individual Insurance License

SECTION V: ADDITIONAL INFORMATION

Carefully read the questions below and check either "YES" or "NO." You should provide a “YES”

answer EVEN IF YOU BELIEVE AN INCIDENT HAS BEEN CLEARED FROM YOUR RECORD OR EVEN IF THE INCIDENT HAD NOTHING TO DO WITH

INSURANCE. Willful misrepresentation of any fact required to be disclosed in any application or accompanying statement is a violation of law.

NOTE:

ADDITIONAL INFORMATION IS REQUIRED if you “YES” to any of the following. See the instructions for this application.

Have you EVER been convicted of a felony? For the purposes of this application, "convicted" includes, but is not limited to,

Yes

having been found guilty by judge or jury or pled guilty or no contest to any felony charge. A "No" response is incorrect if

applicant has had any conviction dismissed, expunged, pardoned, appealed, set aside or reversed, or had its civil rights

restored, had a plea withdrawn or has been given probation, a suspended sentence or a fine, or successfully completed a

diversion program.

Have you EVER had any professional, vocational, business license or certification refused, denied, suspended, revoked or

Yes

restricted, or a fine imposed by any public authority?

Have you EVER withdrawn any application or surrendered any license to avoid any disciplinary action or the denial of a license?

Yes

Have you EVER had any judgment, order or other determination, including any conviction issued or made against you 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 you as defendant, currently pending against you 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 you are an applicant for a bail bond agent license, have you EVER been convicted of theft?

Not applicable

Yes

Have you EVER had an agency contract terminated by an insurance company or managing general agent for any alleged

Yes

cause?

Are you presently indebted to any insurer or any insurance company or managing general agent?

Yes

SECTION VI: EMPLOYMENT HISTORY

List your employment history for the past five years (if none, please explain) and your insurance-

related experience during the past ten years. If more space is required, attach and sign a separate sheet containing the information.

EMPLOYMENT DATES

Employer Name

Type of Business

Position Held

City/State

FROM (mm/yy) TO (mm/yy)

SECTION VII: INSURANCE LICENSE HISTORY

Are you presently, or have you ever been, licensed to transact any kind of

insurance in this state or elsewhere? Yes q q

No q q

If “Yes,” please complete the following information as to each license. If more space is

required, complete and attach a separate list.

Resident or

Non-

State

Kinds of Insurance (life, disability,

Type of License (agent,

DATES HELD

Resident?

property, casualty, etc.)

broker, solicitor, etc.)

FROM (mm/yy) TO (mm/yy)

CONTINUED ON THE FOLLOWING PAGE

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Form L-169 - Application For An Individual Insurance License - State Of Arizona Page 2

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