Form Vsb - Application For Viatical Settlement Broker
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4Resident Fee:
Non Resident Fees:
New Application: $500.00
New Application:
$500.00
Service of Process:
$10.00
Total Amount Enclosed: $____________
Total Amount Enclosed: $_____________
Check Number:
Check Number/s:
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
licensing@oid.ok.gov
APPLICATION FOR VIATICAL SETTLEMENT BROKER
ATTENTION: WE COOPERATE WITH THE OKLAHOMA COUNTY DISTRICT ATTORNEY IN THE PROSECUTION OF BOGUS CHECK WRITERS.
I hereby acknowledge my understanding that an intentional misstatement of fact required to be disclosed on this application
constitutes a violation of the Insurance Code and shall be cause for refusal or revocation of this license.
Law cites include:
The Viatical Settlements Act of 2008, Title 36 § 4055.1 et seq. and Title 365:25-11-1. through Title 365:25-11-11.
PLEASE INITIAL: _______________________
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Type of application:
RESIDENT
NON-RESIDENT
INDIVIDUAL
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CORPORATION
PARTNERSHIP
LIMITED LIABILITY CORPORATION
1.
Applicant’s Name________________________________________________________ DOB: _______/_______/_______
Last
First
Middle
2.
Corporation Name___________________________________________________________________________________
If Corporation, are you authorized by the Secretary of State to transact business in Oklahoma?
Yes____ No____
Please contact the Secretary of State for qualification requirement (405) 521-3911.
2. (A) If there has been a name change, list old name: ________________________________________ License No.:_________
Attach amended articles of incorporation reflecting name change and amended Oklahoma Secretary of State Certificate of
Authority
3.
Applicant’s SSN: ____________________ Company’s FEIN: _______________ Oklahoma License No.:______________
4.
Mailing Address: ____________________________________________________________________________________
City
State
Zip
5.
Telephone Number: _______________________________ Fax Number: _______________________________________
6.
Contact Person: _______________________________________Email:_________________________________________
7.
Principal Business
Address____________________________________________________________________________
City
State
Zip
8.
What state are you domiciled in? _______________________________________________________________________
9.
Has the applicant or any of its employees, partners, members, directors, or officers ever had a Life Settlement Broker,
Viatical Settlement Broker, or insurance license refused, revoked, suspended, or terminated by any insurance department? If
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FORM VSB Rev. 07302013
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