Form Csr-1 - Customer Service Representative Appointment
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CSR-1
Rev. 01242011
OKLAHOMA INSURANCE DEPARTMENT
th
3625 NW 56
, Suite 100
Oklahoma City, OK 73112-4511
(405) 521-3916 or Fax: (405) 522-3642 Toll Free In-State 800-522-0071
CUSTOMER SERVICE REPRESENTATIVE APPOINTMENT
Please type or print clearly.
___________________________
Check here for Title coverage only
CSR LICENSE NUMBER
(Issued by Oklahoma Insurance Department)
CSR’s SS #:_________________________
Applicant’s Name:
(Last)
(First)
(MI)
(SSN#)
Business Address:
(Street)
(City)
(State)
(Zip)
:
(
)
(
)
Date of Birth
Business Phone:
Business Fax:
1. Is the above individual employed or appointed by any other agent, broker or agency?
Yes ____
No ____
2. Has this applicant been convicted of, plead guilty to or nolo contendere to a felony?
Yes ____
No ____
3. Has this applicant committed a violation of any State Insurance Law, or do you believe that this
Yes ____
No ____
applicant has violated or may be currently violating any such law?
If yes to questions 2 and/or 3, please explain in detail on a separate sheet of paper.
4. I agree that the customer service representative shall be housed within the office of my business
and shall not conduct insurance-related business as authorized herein from any other location.
Yes ____
No ____
Furthermore, no advertising, letterhead, or telephone listing of the customer service representative
shall indicate any business address other than that of the below signed.
5. I have instructed and have given to the customer service representative the Oklahoma Insurance
Yes ____
No ____
Laws.
6. All insurance-related business conducted by the customer service representative shall be in the
name of the below agent, broker or agency. As such, I shall be responsible and accountable for all
Yes ____
No ____
acts of the named customer service representative within the scope of such appointment.
Being duly licensed by the State of Oklahoma Insurance Department, I hereby affix my name below in testimony
that I have investigated the applicant’s character and background and that I will supervise the work of the customer
service representative, obligating myself to supervise the customer service representative’s conduct of insurance-
related business and review such work until this license and/or appointment is terminated, revoked, or suspended.
Dated this _________ of _______________________________ 20________
(Signature of Authorized Sponsoring Agent/Broker/Agency)
Print ___________________________________________________________________________
(Sponsoring Agent/Broker/Agency)
Title (Print)
Address:
Oklahoma License Number
City:
(
)
(
)
Business Phone:
Business Fax:
State:
Zip:
If this appointment is disapproved for any reason, a new CSR-1 will be required.
FOR INSURANCE DEPARTMENT USE ONLY
Not approved for title coverage for the following reason(s):
Approved for title coverage:
Processed by:
Date mailed:
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