Application For Adjuster Agency Licensing - Oklahoma Insurance Department Page 2
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3Jurisdiction and Type of License Requested
Check the legal business type, license type(s), line(s) of authority, license type for which you are applying and use the check-box to indicate
any previous license.
Legal Business Type: C—Corporation P—Partnership LLC—Limited Liability Company LLP—Limited Liability Partnership
License Type: I— Insurance Adjuster (Includes Independent Adjuster & Company Staff Adjuster) P—Public Adjuster
Previously
Legal Business Type
Lines of Authority
License Type
Licensed
Fire & Allied
Motor Vehicle
Workers’
Crime &
Yes
C
P
LLC
LLP
Lines (Property)
Casualty
Physical Damage
Compensation
Fidelity Bonds
Crop/Hail
I
P
No
Background Questions
1. Has the business entity or any owner, partner, officer or director ever been convicted of, or is the business entity or any
Yes or
No
owner, partner, officer or director currently charged with a felony whether or not adjudication was withheld?
“Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea
of guilty or nolo contendere, or having been given probation, a suspended sentence or fine.
If you answer yes, you must attach to this application:
a)
a written statement explaining the circumstances of each incident,
b)
a copy of the charging document, and
c)
a copy of the official document which demonstrates the resolution of the charges or any final judgment
2. Does any person who has had their license revoked by the Insurance Commission own an interest in the business entity or
Yes or
No
a business entity in which such person has a majority ownership, whether direct or indirect, own any interest in the
business entity?
3. Have authorities of any state ever refused the firm or any individuals authorized to act on behalf of the firm?
Yes or
No
4. Have authorities of any state ever revoked, suspended, fined or terminated the firm or any individuals authorized to act on
Yes or
No
behalf of the firm?
5. Has the firm’s surety or fidelity bond ever been denied, canceled or resorted to for satisfaction?
Yes or
No
Applicants Certificate and Attestation
The undersigned owner, partner, officer or director of the business entity hereby certifies, under penalty of perjury that:
1. All of the information submitted in this application and attachments is true and complete and I am aware that submitting
false information or omitting pertinent or material information in connection with this application is grounds for license
or registration revocation and may subject me and the business entity to civil or criminal penalties
2. I acknowledge that I am familiar with the insurance laws and regulations of the jurisdictions to which I am applying for
licensure/registration.
______________________________________________________________
__________/_________/_________
Officer, Director, Principal or Partner of the Business Entity Signature
Month
Day
Year
______________________________________________________________
_____________________________
Print Authorized Signer’s Name
Title
Adjuster Agency Rev. 01242011
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Parent category: Legal