Application For Adjuster Agency Licensing - Oklahoma Insurance Department
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OKLAHOMA INSURANCE DEPARTMENT
____ New License
th
3625 NW 56
Suite 100, Oklahoma City, OK 73112-4511
____ License Reinstatement
405) 521-3916 or Fax: (405) 522-3642
____ Name Change
Toll Free In-State 800-522-0071
____ Add Coverage
Resident or
Non-Resident
Oklahoma Insurance Department
Application for Adjuster Agency Licensing
(Please Print or Type)
Business Entity Name/Type of Business Entity
Incorporation/Formation Date
FEIN
(month) ______(day)______(year)______
-
DBA/Trade Name (if applicable)
State of Domicile
Country of Domicile
Business Address
City
State
Zip or Foreign Country
Phone Number
Fax Number
Business Web Site Address
Business E-Mail Address
(
)
-
(
)
-
Mailing Address
P. O. Box
City
State
Zip or Foreign Country
Designated/Responsible Licensed Adjuster
Please identify an Oklahoma licensed Adjuster responsible
for compliance with the insurance laws of this State.
Name_____________________________________
SSN___________________________
Oklahoma License Number___________________
Name_____________________________________
SSN___________________________
Oklahoma License Number___________________
Name_____________________________________
SSN___________________________
Oklahoma License Number___________________
Name_____________________________________
SSN___________________________
Oklahoma License Number___________________
Please identify all members, directors & officers
Please note: The licensee shall notify the Commissioner of all changes among its members, directors, and officers, and all other
individuals designated in the license within fifteen (15) days after the change.
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Name_____________________________________
Title___________________________
SSN___________________________
Please complete
: Amount Paid $ ____________ by check/money order# ________________ Dated __________________
All fees are deemed “earned and non-refundable” by Oklahoma Statute.
We cooperate with the Oklahoma County District Attorney in the prosecution of bogus checks.
Adjuster Agency Rev. 01242011
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