BROKER LICENSE INDIVIDUAL REQUIREMENTS. The following are the basic requirements an applicant must satisfy to obtain a broker license:

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1 COMMONWEALTH OF PENNSYLVANIA INSURANCE DEPARTMENT BUREAU OF PRODUCER LICENSING 1300 Strawberry Square Phone (717) Harrisburg, PA Fax (717) BROKER LICENSE INDIVIDUAL REQUIREMENTS An insurance certificate or license is required to solicit, sell, negotiate, or give advice regarding insurance contracts in the Commonwealth of Pennsylvania. The Insurance Department is empowered by the Insurance Department Act of 1921, as amended, to qualify individuals who wish to operate as agents. Title 31, Chapters 37 and 39 sets forth the lawful standards and requirements for insurance agents and brokers. The following are the basic requirements an applicant must satisfy to obtain a broker license: 1) be at least 18 years of age; 2) maintain a business or legal address in the Commonwealth of Pennsylvania; 3) be able to read and write in the English language; 4) pass the appropriate examination(s) required by statute or meet the examination exemption requirement (31 Pa. Code 37.23) or if non-resident, provide proof of licensure in good standing in home state for the same line of authority for which applying; 5) possess the requisite professional competence, general fitness and integrity of character; and 6) the applicant is not an employee of a public utility that conducts business in Pennsylvania. To apply for a broker license, an applicant must: 1) pass the appropriate examination or provide proof that the applicant meets the examination exemption requirements, i.e., provides a copy of a CPCU, CLU, or CIC designation diploma, or if non-resident, provide letter of certification of good standing from home state; Please note that pursuant to 31 Pa. Code 37.25, to be eligible to take the broker s examination for: a) the property and casualty line of authority, you must be certified and appointed as an agent with both property and casualty lines of authority or you must be currently licensed as a property and casualty broker in another state; and b) the life and accident and health lines of authority, you must be certified and appointed as an agent with both the life and accident and health lines of authority or you must be currently licensed as a life, accident and health broker in another state. It is your responsibility to provide this information to the testing administrator. 2) complete a verified IDL-11 application (see IDL-11 Instructions); 3) make sure the appropriate fee is included with the application (a fee is not required for a broker that is already licensed and is adding a line of authority); and 4) forward the completed application to the Insurance Department within the appropriate timeframe. The application will be returned, if: 1) you do not meet the examination exemption requirements (31 Pa. Code and/or 37.24) and you have not passed the appropriate examination; 2) your examination results are more than one year old (test results are valid for one year from the date of the examination, 31 Pa. Code 37.31(e)); 3) the notary is more than 90 days old; 4) if non-resident, the letter of certification is more than 90 days old; 5) the appropriate fee, if required, is not included; and 6) the application is incomplete in any manner, including not providing required attachments and/or explanations to the questions you answered in the affirmative.

2 Page 2 To expedite processing, please make sure the application is complete and include a copy of your test scores, if appropriate. If you meet all of the requirements to obtain a broker license and the Insurance Department has verified that there is nothing in your background that should prohibit you from obtaining a license, the appropriate license will be issued to you. Additional information is available in the Pennsylvania Insurance Department Licensing Information Bulletin. This Bulletin provides general guidelines regarding licensing and how to schedule an examination. The Bulletin is available by contacting Experior Assessments, LLC, the Insurance Department s testing vendor, at or visit Experior Assessments website at or by contacting the Bureau of Producer Licensing at the above address and telephone number Sincerely yours, Bureau of Producer Licensing

3 INSTRUCTIONS FOR IDL-11 IDENTIFICATION- INCLUDE ALL INFORMATION UNDER THIS SECTION. LAST NAME, FIRST NAME, MIDDLE INITIAL, SOCIAL SECURITY NUMBER, MAILING ADDRESS, RESIDENCE ADDRESS, AND BUSINESS ADDRESS. Please note that street address must be provided for the residence address; P.O. Boxes are not acceptable. CERTIFICATE- CHECK THE ONE THAT APPLIES UNDER SECTION A. CHECK TYPE AND STATUS- NEW BROKER IF YOU ARE NOT CURRENTLY LICENSED IN PENNSYLVANIA AS A BROKER. CHECK EXISTING BROKER IF YOU ARE CURRENTLY LICENSED AS A BROKER IN PENNSYLVANIA AND ADDING A LINE OF AUTHORITY. CHECK THE ONE THAT APPLIES UNDER SECTION B. Resident is defined as a person whose business address or legal residence is located in Pennsylvania. A nonresident is defined as a person whose business and legal residence is outside of Pennsylvania. Note: If nonresident, include a home state letter of certification, confirming that you are licensed in the home state for the same line(s) of insurance being applied for, dated within 90 days of filing. If currently licensed as a resident in another state and moving to Pennsylvania, include a letter of clearance from your present or previous home state. Failure to provide such documentation will result in the return of your application as incomplete. LINES OF CHECK THE ONE THAT APPLIES UNDER SECTION A. AUTHORITY- CHECK THE LINES OF AUTHORITY FOR WHICH THE APPLICANT IS APPLYING UNDER SECTION B. TRADING NAMES-COMPLETE THIS SECTION, ONLY IF YOU ARE GOING TO USE A TRADING AS NAME OR FICTITIOUS NAME. Include a copy of the Department of State approved fictitious name filing or an explanation as to why you do not need to file the fictitious name with the Pennsylvania Department of State. ATTACHMENTS- CHECK ONLY THE ATTACHMENTS YOU ARE INCLUDING WITH THE APPLICATION. APPLICATIONS WILL BE REJECTED IF REQUIRED ATTACHMENTS ARE NOT INCLUDED. MANDATORY THIS SECTION IS MANDATORY. INCLUDE CURRENT EMPLOYMENT- EMPLOYER, ADDRESS, START DATE, END DATE AND HISTORY OCCUPATION. IF LESS THAN TWO YEARS, INCLUDE PREVIOUS EMPLOYER. HISTORY MUST INCLUDE TWENTY-FOUR MONTHS PRIOR TO DATE OF APPLICATION. MANDATORY BACKGROUND INFORMATION- MANDATORY APPLICANTS CERTIFICATION ANSWER EACH QUESTION YES OR NO, AFTER READING CAREFULLY.AS REQUESTED FOR CERTAIN AFFIRMATIVE ANSWERS, INCLUDE EXPLANATIONS AND ATTACHMENTS. FAILURE TO PROVIDE THE REQUIRED EXPLANATIONS OR ATTACHMENTS WILL RESULT IN YOUR APPLICATION BEING RETURNED TO YOU AS INCOMPLETE. THIS SECTION MUST BE COMPLETED BY A NOTARY PUBLIC, AND THE NOTARY PUBLIC CANNOT BE THE APPLICANT. NOTARY DATE CANNOT BE OVER NINETY(90) DAYS OLD. Remember to attach check or money order payable to the Commonwealth of Pennsylvania. Fees for resident broker license is $40 and non-resident fees are reciprocal with home state. A fee is not required to add an additional line of authority.

4 COMMONWEALTH OF PENNSYLVANIA INSURANCE DEPARTMENT BUREAU OF PRODUCER LICENSING IDL-11 BROKER LICENSE APPLICATION (Individual) PART I IDENTIFICATION SOCIAL SECURITY NUMBER - - DATE OF BIRTH / / Month Date Year FULL LEGAL NAME Last Name First Name Middle Initial (Jr/Sr/III) (NOTE: THE FULL LAST NAME MUST BE USED-NO NICKNAMES. ANY TRADING NAMES MUST BE LISTED IN TRADING AS NAMES SECTION.) MAILING ADDRESS STREET CITY STATE ZIP CODE ADDRESS RESIDENCE ADDRESS (If different than above) STREET ( ) CITY STATE ZIP CODE HOME TELEPHONE NUMBER BUSINESS ADDRESS STREET (Street Address Required) ( ) CITY STATE ZIP CODE BUSINESS TELEPHONE NUMBER *ALL ADDRESSES MUST BE PROVIDED AND PO BOXES ARE NOT ACCEPTABLE FOR RESIDENCE ADDRESS PART II CERTIFICATE TYPE AND STATUS A. CHECK ONE: B. CHECK ONE: NEW BROKER (TEST REQUIRED) RESIDENT EXISTING BROKER REQUESTING ADDITIONAL LINE CONVERSION TO RESIDENT (ATTACH IN FORCE LICENSE-NOT A COPY) (ATTACH HOME STATE CLEARANCE LETTER) NONRESIDENT (ATTACH LETTER OF CERTIFICATION DATED WITHIN 90 DAYS OF FILING) PART III LINES OF AUTHORITY A. CHECK ONE: B. CHECK THOSE THAT YOU ARE APPLYING FOR: PASSED EXAMINATION 1100 LIFE, ACCIDENT AND HEALTH (SCORES VALID FOR ONE YEAR) 1200 PROPERTY AND CASUALTY PROFESSIONAL DESIGNATION NOTE: CERTAIN REQUIREMENTS MUST BE MET SUCH AS HOLDING AN AGENT S CERTIFICATE (ATTACH PROOF) OF QUALIFICATION OR BROKERS LICENSE TO QUALIFY TO SUBMIT THIS APPLICATION. PART IV TRADING NAMES IF THE APPLICANT TRANSACTS BUSINESS UNDER AN ASSUMED TRADE NAME, PROVIDE THE FULL NAME IN THE SPACE PROVIDED. IF NO ASSUMED TRADE NAME IS USED, LEAVE BLANK, INDIVIDUALS CANNOT ASSUME THE NAME OF A CORPORATION OR PARTNERSHIP. PART V ATTACHMENTS LETTER OF CERTIFICATION DATED WITHIN 90 DAYS OF FILING NEEDED BY NONRESIDENTS LETTER OF CLEARANCE NEEDED TO CONVERT TO A RESIDENT DEPARTMENT OF STATE APROVED FICTITIOUS NAME FILING AFFIDAVIT IF YES RESPONSE TO QUESTION 4d * OTHER IDL 11 (01/12/00)

5 SOCIAL SECURITY NUMBER AS PROVIDED ON REVERSE SIDE - - IDL-11 ATTACH YOUR CHECK OR MONEY ORDER FOR THE FEE TO THIS COMPLETED APPLICATION. FAILURE TO INCLUDE PROPER PAYMENT WILL RESULT IN REJECTION OF THE APPLICATION. CHECK AMOUNT $ CHECK NO. NOTE: FEES: RESIDENT-$40 FOR INDIVIDUAL OR ACTIVE OFFICER; NON-RESIDENT-RECIPROCAL WITH HOME STATE PART VI BACKGROUND INFORMATION YES NO 1. DO YOU NOW HOLD OR HAVE YOU EVER HELD A RESIDENT INSURANCE LICENSE IN ANY OTHER STATE OR CANADA? (IF YES AND THE LICENSE IS STILL IN FORCE, ATTACH A HOME STATE LETTER OF CERTIFICATION. IF THE LICENSE IS NOT IN FORCE, ATTACH A CLEARANCE LETTER FROM THE STATE WHERE YOU LAST HELD A RESIDENT LICENSE.) 2. HAVE YOU EVER BEEN PENALIZED OR FINED, HAD A LICENSE REFUSED, SUSPENDED OR REVOKED BY THIS DEPARTMENT OR THE INSURANCE DEPARTMENT OF ANY OTHER STATE OR PROVIDENCE OF CANADA OR IS ANY SUCH ACTION NOW PENDING? (IF YES, PROVIDE A FULL EXPLANATION ON A SEPARATE SHEET OF PAPER.) 3. HAVE YOU EVER BEEN CONVICTED OF OR PLED NOLO CONTENDERE (NO CONTEST) TO ANY MISDEMEANOR OR FELONY OR CURRENTLY HAVE PENDING MISDEMEANOR OR FELONY CHARGES FILED AGAINST YOU? (IF YES, GIVE DATE, NAME AND ADDRESS OF COURT, TYPE OF CHARGE (i..e. FELONY), BASIS OF CHARGE AND OUTCOME OR SENTENCE AND INCLUDE A CERTIFIED COPY OF THE COURT RECORD.) 4. ARE YOU AN OFFICER OR EMPLOYEE OF A FINANCIAL INSTITUTION AS DEFINED BY ACT 40, SECTION 601 (40 P.S. 231) OR A SUBSIDIARY OF A FINANCIAL INSTITUTION? IF YES, PROVIDETHE FOLLOWING: a) NAME OF INSTITUTION; b) TYPE OF INSTITUTION (i.e. national bank, state chartered bank, bank holding company, etc.): c) IF SUBSIDIARY OR AFFILIATE, EXPLAIN RELATIONSHIP TO FINANCIAL INSTITUTION: AND d) IF YOU ARE AN OFFICER OR EMPLOYEE OF A FINANCIAL INSTITUTIO9N AND THE FINANCIAL INSTITUTION IS NOT LICENSED, PROVIDE NOTARIZED AFFIDAVIT STATING YOU ARE NOT SELLING INSURANCE ON BEHALF OF THE FINANCIAL INSTITIUTION. 5. IF YOU ARE NOW OR HAVE EVER BEEN ENGAGED IN ANY PHASE OF THE INSURANCE BUSINESS, IS YOUR ACCOUNT WITH ANY COMPANY, AGENT OR INSURED NOW DELINQUENT OR IN DISPUTE? (IF YES, PROVIDE A FULL EXPLANATION ON A SEPARATE SHEET OF PAPER.) 6. ARE YOU FAMILIAR WITH AND DO YOU AGREE TO ABIDE BY ALL THE LAWS AND REGULATIONS PERTAINING TO THE BUSINESS OF INSURANCE IN THE COMMONWEALTH OF PENNSYLVANIA? 7. ARE YOU THE SUBJECT OF AN ORDER ISSUED BY THE COURT OR DEPARTMENT OF PUBLIC WELFARE UNDER 23 Pa.C.S.A (DENIAL OR SUSPENSION OF LICENSES) RELATING TO DOMESTIC REALTIONS, FAILURE TO PAY CHILD SUPPORT, ETC? PART VII EMPLOYMENT HISTORY LIST IN CHRONOLOGICAL ORDER YOUR CURRENT AND PREVIOUS RECORD OF EMPLOYMENT OR EDUCATION COVERING AT LEAST 2 YEARS PRECEDING THE DATE OF APPLICATION CURRENT EMPLOYER Name Address From To Occupation PREVIOUS EMPLOYER (IF APPLICABLE) Name Address From To Occupation PART VIII APPLICANT S CERTIFICATION I DO HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS AND INFORMATION ARE TRUE AND CORRECT AND THAT ANY LICENSE ISSUED IN CONSEQUENCE HEREOF SHALL BE CONTINGENT UPON THE TRUTH OF THESE STATEMENTS. FURTHERMORE, I CONFIRM THAT I UNDERSTAND FULLY THE INSURANCE LAWS AND REGULATIONS OF PENNSYLVANIA REGARDING BROKER ACTIVITIES. NOTE: FALSE STATEMENTS MAY RESULT IN CRIMINAL PENALTIES, APPLICATION DENIAL, ADMINISTRATIVE ENFORCEMENT ACTION OR ALL OF THE AFOREMENTIONED. SUBSCRIBED AND SWORN TO BEFORE ME THIS (SEAL) Day of Year Notary Public Applicant Signature Applicant Name (Printed or Typed) Commission Expires NOTE: APPLICATION EXECUTED MORE THAN 3 MONTHS PRIOR TO THE DATE OF FILING WITH THE DEPARTMENT WILL NOT BE ACCEPTED. INFORMATION PROVIDED BY THE APPLICANT IN COMPLETING THIS FORM MAY BE SUBJECT TO PUBLIC DISCLOSURE UNDER PA LAW. IDL 11 (01/12/00)

6 BOND NUMBER: KNOW ALL MEN BY THSES PRESENTS, That we As Principal, and the Company, a corporation organized and existing under the laws of the State of, as an admitted Surety Insurer, are held and firmly bound unto the Insurance Commissioner of the Commonwealth of Pennsylvania in the penal sum of $. For the payment of which, well and truly to be made, we and each of us bind ourselves, our heirs, executors, personal representatives, successors and assigns, firmly by these presents. THE CONDITION OF THE FOREGOING OBLIGATION IS SUCH, That, Whereas, the said Principal has applied to the Insurance Commissioner of the Commonwealth of Pennsylvania for a license to act as a nonresident insurance broker, and in accordance with the provisions of Section 212, of The Insurance Department Act of may 17, 1921, P.L. 789, as amended by Act of May 5, 1945, P.L. 430, is required to file a corporate surety bond with the Commissioner in the same character and amount, as is required of a Pennsylvania broker seeking similar license in the for the benefit of any person who may suffer loss resulting from fraud or dishonesty or failure to account on the part of said Principal while acting or purporting to act under. NOW, THEREFORE, if such license is issued to the said Principal and if he shall comply in all respects with its terms and with the laws and regulations of the Commonwealth of Pennsylvania pertaining to insurance brokers, and shall indemnify any person who may suffer loss resulting from the fraud of dishonesty of the said Principal while acting or purporting to act under such license, then this bond shall be void and of no effect; otherwise, to remain in full force and effect. This bond shall be effective as of the date hereof unless amended by endorsement to be concurrent with date of issuance of the brokers license, and shall remain in force and effect until the Surety is released from liability by the written order of the Insurance commissioner. Such release shall not affect any liability incurred or accrued hereunder prior to said release. In no event shall the Surety s aggregate liability hereunder for all losses exceed the penal sum of $. IN WITNESS HEREOF, the said principal has hereunto set his hand and seal and the said Surety has caused these presents to be signed by its duly authorized officer and its seal to be hereto affixed this day of Year. Signature of Principal is an individual Name of Principal is a firm or corporation BY Authorized Officer Title Name of Surety Authorized Officer Title NRBond(01/12/00)

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