Form Vsb - Application For Viatical Settlement Broker (Page 2 of 4) in pdf

you answer this question with a “yes” response, give details on a separate sheet, and label it as, “Response to Question

9”.

Yes____ No____

10.

Have the Authorities of any state ever called the applicant or any of its employees, partners, members, directors, or officers

before them for any alleged violation(s) of insurance laws on any allegations of fraudulent or dishonest practices? If you

answer this question with a “yes” response, give details on a separate sheet, and label it as, “Response to Question

10”.

Yes____ No____

11.

Has the applicant or any of its employees, partners, members, directors, or officers ever entered a consent order with any state

insurance authority? If you answer this question with a “yes” response, give details on a separate sheet, attach any

order and label it as, “Response to Question 11”.

Yes____ No____

12.

Has the applicant or any of its employees, partners, members, directors, or officers ever been found guilty of fraudulent or

dishonest practices, or found guilty of a felony or any misdemeanor of which criminal fraud is an element, or is otherwise

shown to be untrustworthy or incompetent? If you answer this question with a “yes” response, give details on a separate

sheet, attach any order and label it as, “Response to Question 12”.

Yes____ No____

ALL REQUIREMENTS LISTED BELOW MUST BE INCLUDED WITH APPLICATION ----EXCEPT

in the case of a life insurance producer who has been duly licensed as a resident insurance producer with

a life line of authority in this state or his or her home state for at least one (1) year and is licensed as a

nonresident producer in this state; IN THAT CASE provide completed application with applicable fees,

Exhibit D, Designation of Insurance Commissioner as Agent for Service of Process (if applicable),

notarized signature and completion of Declaration page to the Oklahoma Insurance Department.

Exhibit A

Pursuant to 36 O.S. §4055.3.(F)(4)(b) provide evidence of a surety bond executed and issued by an insurer

authorized to issue surety bonds in this state, a policy of errors and omissions insurance issued by an insurer

authorized to do business in Oklahoma, or a deposit or cash, certificates of deposit, securities or any combination

thereof in the amount not to exceed Fifty Thousand Dollars ($50,000)

Exhibit B

Pursuant to 36 O.S. §4055.3(F)(5) a legal entity must provide a certificate of good standing from the state of its

domicile

Exhibit C

Pursuant to 36 O.S. §4055.3(D) if application is for a LEGAL ENTITY, disclose the identity of all stockholders,

partners, officers, members and employees affiliated with entity. The list MUST include the following information

and may be provided under separate cover:



Name



Social Security Number



Resident Address



Position



Signature



Percentage of ownership of all persons responsible for the conduct of affairs of the applicant. Include

past work experience and educational background.

Exhibit D

Attach current Anti- Fraud Plan pursuant to 36 O.S. §§ 4055.3(F)(6),4055.13(G).

2 of 4

FORM VSB Rev. 07302013

Form Vsb - Application For Viatical Settlement Broker Page 2

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