APPLICATION FOR INDIVIDUAL AGENT LICENSE

Transcription

1 APPLICATION FOR INDIVIDUAL AGENT LICENSE Acn Gn Infomon Gud bgnnng on g 13. Th con fom o b ud by ndvdu no qud o qufyng xmnon hough Pon VUE. I mu b yd o nd n nk. Tho cn qud o k qufyng xmnon mu conc Pon VUE o fo con nfomon nd xmnon von. A con ubjc o fuh vw. Any ffmv on o cnng quon my xnd ocng m. Fu o dco cmn hoy nfomon my u n dn of cn. P I To b comd by ndvdu cn Acn mu choo ony on cn y. Tho who wh o y fo mo hn on cn y mu ubm con nd f fo ch y. Adju houd d PART II of h con bfo connung. Lcn Ty (chck ony on con): Gn Ln Lf, Accdn & Hh Lmd Ln Adju A Ln Gn Ln Poy & Cuy Couny Muu Adju Poy & Cuy Lf Inunc Svc Rnv Adju - Wok Comnon Lf Inunc No Excdng $25,000 Mngng Gn Agn Adju Tn Fun Pngmn Lf Suu Ln Adju Emgncy Lf & Hh Inunc Couno Rk Mng Adju A Ln Dgnd Hom S Tx Fu-Tm Hom Offc Sd Emoy Pubc Inunc Adju P&C Dgnd Hom S Tx Pon Ln Poy nd Cuy Pubc Inunc Adju Tn Adju Wok Comnon Dgnd Hom S Tx Lcn F: F $50 cn y, o $150 fo moy cn. $75 f qud fo cn h h bn xd fo mo hn 90 dy bu hn on y. (Tx Inunc Cod (TIC) ) Mk chck o mony od yb o h Tx Dmn of Inunc. A cn f nonfundb nd nonnfb. No f qud fo Adju-Tn. $20 f qud fo 90 dy Adju-Emgncy Acn Infomon P d cfuy nd ovd qud nfomon. 1 Acn Fu Lg Nm ncknm nd bbvon no ccb. LAST NAME FIRST NAME MIDDLE NAME SUFFIX 2 Acn Soc Scuy Numb, D of Bh nd Dym Phon Numb Th con cnno b ocd whou h nfomon. Dcou of Soc Scuy Numb qud by h Tx Fmy Cod SOCIAL SECURITY NUMBER DATE OF BIRTH (MM/DD/YY) DAY TIME PHONE NUMBER EXT 3 Mng Add (qud) Th h dd of cod wh TDI. STREET, PHYSICAL LOCATION, ROUTE OR P O BOX APT, STE, ETC. CITY STATE ZIP CODE Tx Dmn of Inunc 1/16

2 4 Lg Rdn Add (qud) Th dd wh you v. STREET, PHYSICAL LOCATION, ROUTE OR P O BOX APT, STE, ETC. CITY STATE ZIP CODE 5 Offc Bun Add (qud) Th mu b you my offc dd wh you w mnn bun cod of Tx nunc ncon. STREET, (PHYSICAL LOCATION REQUIRED; P.O.BOX NOT ACCEPTED) APT, STE, ETC. CITY STATE ZIP CODE 6 Acn E-m Add (qud) E-m w b ud ony oon whn coondng wh TDI. ADDRESS Acon w no b ocd un o documnon o d cvd nd vw comd. A con ubjc o fuh vw. Any ffmv on o cnng quon my xnd ocng m. Fu o dco cmn hoy nfomon my u n dn of cn. 7 Excudng ffc voon nd f offn DWI:. Do you cuny hv ny ndng mdmno o fony chg (by ndcmn, nfomon, o ny oh numn) fd gn you n Tx, n ny oh o by h fd govnmn? No Y b. Hv you v bn convcd of ny mdmno o fony offn n Tx, n ny oh o by h fd govnmn? No Y c. Hv you v hd djudcon dfd on ny mdmno o fony chg o offn n Tx, n ny oh o by h fd govnmn? No Y d. Hv you v vd ny od of obon fo ny mdmno o fony offn n Tx, n ny oh o by h fd govnmn? No Y If you nw Y o ny of quon 7 d, you mu ubm ogn cfd co of h chgng documn, ndcmn, nfomon, o ny oh chgng documn, judgmn of convcon, nd/o dfd djudcon od, obon od, od mnng obon, communy uvon nd/o o cfc fo ch nd vy cm o offn. If h cou hy no ong hv h cod, hv h cou ovd u wh on h hd ng h fc. If you w d ony nd no ocud, ovd cod ch fom h o judcon ndcng fn doon. You mu ubm mn dcbng h ccumnc dng o h offn(). You mu ncud you g h m() of h offn().you my ovd of commndon fom ny on n conc wh you h w of you cmn. 8 Hv you v d fo of conn, qud und con 18 U.S.C. 1033(), fom ny nunc guoy offc fom Tx o ny oh S? No Y If you nw Y, h con w no b ocd un you ovd fu d of h oucom of h ocdng nd uong documn o h dmn. If you nw No, nd you hv bn convcd of ny cmn fony nvovng dhony o bch of u, o n offn und con 18 U.S.C. 1033, h con w no b ocd un you ubm gnd nd nozd qu fo wn con- n wh uong documnon o h dmn. 9 Hv you o h ny cooon, nh, ocon o fm n whch you w dco, offc, hhod, mng, mmb o n, v bn h ubjc of n dmnv o g con fd by Tx o ny oh nunc dmn, o fnnc guoy gncy, o of n con fd on bhf of Tx o ny oh o by h fd govnmn bd on gd voon of o fd nunc, cu o fnnc guoy w h you hv no vouy od o h Tx Dmn of Inunc? Tx Dmn of Inunc 2/16

3 No Y If you nw Y, cn w no b ud un fu d of h dmnv o g con ovdd. 10 A you ndbd o ny ocyhod, nunc o nunc comny, nunc gncy, gn gn, mngng gn gncy, mum fnnc comny o cou ond qudo fo mum cocd o common nd, o hv ny cm o judgmn bn fd gn you fo nng mum o common? No Y If you nw Y, cn w no b ud un fu d of h ndbdn ovdd. 11 Hv you v hd n gncy conc o comny onmn cncd fo cu (.g., mnon, moon, c.)? No Y If you nw Y, cn w no b ud un fu d ovdd. Cncon fo cu do no ncud cncon du o cn xon (nonnw). 12 Dung h 6 monh, hv you d fo o cvd moy cn of h y fo whch you now yng? No Y If you nw Y, moy cn w no b ud. A moy cn my no b nwd o ud mo hn onc n concuv x-monh od o h m cn. 13 Do you cuny hod ny nunc gn cn, dju o ubc nunc dju cn n ny oh hn Tx o hv you hd ny nunc gn cn, dju o ubc nunc dju cn n ny oh hn Tx whn h fv y? No Y If you nw Y, you mu ovd h foowng: Acn who hv hd dn cn n noh whn h vou fv y fom h d of h con mu ch Cnc L fom h Inunc Common n h () n whch h cn w vouy cnd. A Poduc Db nou howng h mnon of h cn n h cn vou dn () cn k h c of Cnc L. Acn hodng cun dn cn n noh mu ch n ogn Cfc of Good Sndng fom h Inunc Common n h cn of dnc. Th Cfc of Good Sndng mu b dd whn 90 dy of c of h comd con. A Poduc Db n ou howng h cun cn hd n h cn dn wh h m cn y h you yng fo cn k h c of L of Cfcon. 14 Th con fo cn I vouy hd h xd fo mo hn 90 dy bu hn on y. I w ch h qud $75 cn f. (TIC ) No Y Pvou Lcn Numb 15 Do you qufy ny of h foowng?. My vc mmb mn on who cuny vng n h md foc of h Und S, o n v comonn of h md foc ncudng h Non Gud, o n my vc of ny. No Y b. My ou mn on who md o my vc mmb who cuny on cv duy. No Y c. My vn mn on who h vd n h Amy, Nvy, A Foc, Mn Co, o Co Gud of h Und S, o n n uxy vc of on of ho bnch of h md foc. No Y NOTE: If you nw Y o, b, o c n quon 15, mk h o of h fon g of h con wh hghghd M. Tx Dmn of Inunc 3/16

4 P II Adju, Adju Tn nd Emgncy Adju (Pubc Inunc Adju u P III) A Ln Adju, Poy & Cuy Adju, nd Wok Comnon Adju Ony Adju my dd ddon qufcon whou comng nw con by ubmng o TDI coy of h xng dju cn ong wh coy of h ovd cou cfc, o by ng h Tx xmnon ovdd by Pon VUE. Th Cfc of Comon mu how h whn h 12 monh h dju h comd cfd dju -cnng ducon ogm nd d n xmnon. 1 Adju Acn Mu b comd wh h nm of h fm o nu wh whom hy w b moyd o; f f-moyd, wh h cn nm. NAME OF FIRM OR INSURER (OR APPLICANT NAME, IF SELF-EMPLOYED) 2 I hv qufd fo h dju cn cd on g 1 nd hv: (A o Tx dn/nondn coc dju cn ony. Adju Dgnd Hom S cn k o #3.) chd cou Cfc of Comon cfyng h whn h 12 monh I comd Tx dju -cnng ducon ogm nd d xmnon, o cun m dn dju cn o qufd wh cun m cn dgnd hom n good ndng n h S of fcd n h Non Aocon of Inunc Common Poduc Db o by h chd L of Cfcon fom h cnng, o chd my CPCU dgnon o Aoc n Cm (AIC) cfcon. 3 Nondn Adju Dgnd Hom S Tx Acn Ony I m dn of noh h do no cn dju fo h n of uhoy ough. I d n h m dn of Tx o c n dju n h, nd I qu h Tx b h dgnd hom of h dju cn fo whch I m yng (TIC 4101). I hv qufd fo h Tx dju dgnd hom Tx cn cd on g 1 nd hv: chd cou Cfc of Comon cfyng h whn h 12 monh you comd Tx cfd dju -cnng ducon ogm nd d n xmnon, o chd my CPCU dgnon o Aoc n Cm (AIC) cfcon. I undnd h by dgnng Tx h hom, I m ubjc o Tx cn qufyng xmnon nd comnc wh Tx dju connung ducon nd fngnng qumn. (Tx Inunc Cod (TIC) , nd 28 Tx Admnv Cod (TAC) , Tx Inunc Cod (TIC) ) No Y 4 Adju Tn Rgon An Adju Tn qud o undgo ducon nd nng n dju und h dcon nd uvon of cnd onong dju. Auhozon o c n Adju Tn my no xcd 12 monh. Th Adju Tn gon my no b nwd. An Adju Tn mu b onod by cnd dju. Th onong cnd dju mu com h foowng cfcon: Th o cfy h h cn w undgo ducon nd nng n dju und my dcon nd uvon qud n Tx Inunc Cod (TIC) SIGNATURE OF SPONSORING LICENSED ADJUSTER DATE SIGNED (MM /DD/YY) PRINT LEGAL NAME OF SPONSORING LICENSED ADJUSTER TDI LICENSE NUMBER OF SPONSORING ADJUSTER Tx Dmn of Inunc 4/16

5 5 Emgncy Adju An Emgncy Adju Lcn my b ud o n ndvdu o dju o u of coh o mgncy. Th onong cnd dju o nunc comny mu ovd cfc d of h coh qung h unc of n Emgncy Adju Lcn. Th d mu ncud h d, ocon, y of coh, nd coy of offc noc o oh m hd y noc() of h coh o mgncy. An Emgncy Adju mu b onod by h cnd dju o cnd nd ovd nunc comny. Th mng dd of h Emgncy Adju ono mu b ovdd. Emgncy Adju Lcn ud fo 90 dy. Emgncy Adju cn no qud o ovd fngn. Povd ocon() nd d of h coh h h bov-nmd cn nnd o wok. 6 Cfcon fo Emgncy Adju - Th o cfy h h bov-nmd cn w b wokng coh cm h bov ocon() ung fom h coh nmd n h chd offc noc. I w b onb fo h o o cm cc of h Emgncy Adju Lcn hod qud n Tx Inunc Cod (TIC) SIGNATURE OF SPONSORING LICENSED ADJUSTER OR SPONSORING COMPANY OFFICIAL DATE SIGNED (MM/DD/YY) Pn g nm of onong cnd dju o comny offc nd onong comny: NAME TDI LICENSE # OF SPONSORING ADJUSTER SPONSORING COMPANY NAIC # MAILING ADDRESS OF SPONSORING ADJUSTER OR SPONSORING INSURANCE COMPANY BUSINESS PHONE NUMBER (10 DIGIT) CITY STATE ZIP CODE P III Pubc Inunc Adju Ony Pubc Inunc Adju cn cn nd n gon cn mu com h of h con. 1 Lcnd Sono - Povd h nm of h cuny cnd fm o on fo whom you w b moyd ubc nunc dju (PIA), o f f-moyd, n you nm. NAME OF EMPLOYER (OR APPLICANT NAME, IF SELF-EMPLOYED) EMPLOYER S TEXAS PIA LICENSE NUMBER 2 Pubc Inunc Adju Tn Rgon A ubc nunc dju n qud o g nd undgo ducon nd nng ubc nunc dju und h dcon nd uvon of cnd onong ubc nunc dju. Auhozon o c ubc nunc dju n my no xcd 180 dy, bu my b nwd, o ong h gn do no hod ny mo hn wo cfc, ncudng nw, whn n 18 monh od. A n cfc my b nwd by fng noh fuy comd con wh h qud $50 f wh h dmn no mo hn 30 dy o o h xon of n xng n cfc. Th onong cnd ubc nunc dju mu com h foowng cfcon: I cfy h h bov-mnond ubc nunc dju n gon cn w undgo ducon nd nng n dju und my dcon nd uvon qud n Tx Inunc Cod nd h I connu o m h ubc nunc dju fnnc onby qumn. SIGNATURE OF SPONSORING LICENSED PUBLIC INSURANCE ADJUSTER DATE SIGNED (MM/DD/YY) LEGAL NAME OF SPONSORING LICENSED PUBLIC INSURANCE ADJUSTER TDI LICENSE # OF PIA SPONSOR 3 Fnnc Ronby Ech ubc nunc dju cn cn nd n gon cn mu dmon oof of fnnc onby wh uy bond xcud wh h cn o nc n h moun of no hn $10,000 yb o h Tx Dmn of Inunc on bond fom vb S Tx Inunc Cod, nd 28 Tx Admnv Cod Th ogn bond mu b chd o h con. Tx Dmn of Inunc 5/16

6 I hv chd my ogn Pubc Inunc Adju Bond. No Y 4 Fngn A dn nd nondn ubc nunc dju cn cn nd n gon cn mu f wh h con n conc fngn c o c fom by Moho Tu USA confmng n ogn fngn cd nd comd FAST Fngn Cd Scn Auhozon Fom wh $39.70 chck o mony od yb o Moho Tu USA w n o Moho Tu USA. If fngn w vouy ubmd o TDI fo noh con nd h cn connu o hod n cv cn, hn fngn c no qud. Fo com nfomon gdng fngnng, g 12 of h fom. Fngn Rc fom Moho Tu USA o Pon VUE ( g 12 fo com fngnng nucon) chd, o I hod cv TDI Lcn Numb, nd vouy ubmd fngn o TDI. Fngn ovdd fo h con h b ud o chck cmn hoy cod of h Tx Dmn of Pubc Sfy nd h Fd Buu of Invgon n ccodnc wh cb u. 5 Cmn Hoy Rcod Ech nondn ubc nunc dju cn cn nd nondn n gon cn mu f wh h con n ogn cmn hoy cod of h cn obnd fom h w nfocmn gncy of h cn of dnc. I hv chd my ogn cmn hoy cod. No, I m dn of Tx Y, h cod chd. 6 Pubc Inunc Adju Conc Rqumn Effcv Jnuy 1, 2014, conc qumn und mndd Tx Admnv Cod (TAC) , nd y o cn fo Pubc Inunc Adju (PIA) cn. Th conc you oo o u mu b ubmd wh h ogn PIA cn con. P vw you conc o nu comnc wh conc qumn ound n h TAC. TDI h dvod Fom FIN535, Pubc Inunc Adju Conc h conn h qud ndd conc ngug. Th fom my b vwd Th fu by Pubc Inunc Adju o u oy uhozd nd ovd conc my u n unon, nonnw, vocon of h Pubc Inunc Adju cn, o oh dmnv ny (f. TAC (f)).. I hv vwd TDI fom FIN535 nd I w b ung h conc fom wh my cn onc cnd. No Y If no, nw 6b bow b. I hv dvod my own conc fom h m qumn ound n TAC nd I hv chd coy of my ood conc fom fo TDI vw nd ov. No Y No: You con fo PIA cn cnno b ovd un you hv gd n ovd conc wh h dmn. 7 Agn fo Svc of Poc A nondn cn fo ubc nunc dju cn mu ovd h nm nd dd of h gn fo vc of oc n h S of Tx qud n Tx Inunc Cod, NAME OF TEXAS AGENT FOR SERVICE OF PROCESS TEXAS ADDRESS OF AGENT FOR SERVICE OF PROCESS CITY STATE ZIP CODE P IV Suu Ln Agn Ony To qufy fo Tx Suu Ln Lcn, you mu hod cun Tx Gn Ln-Poy nd Cuy Lcn o cun Tx Mngng Gn Agn Lcn (TIC ). Povd you undyng cn y nd cun Tx cn numb: UNDERLYING LICENSE TYPE TDI LICENSE NUMBER Tx Dmn of Inunc 6/16

7 P V Inunc Svc Rnv Ony Cfc fo Inunc Svc Rnv Mu b comd by h onng cnd Gn Ln Poy nd Cuy Agn o Pon Ln Poy nd Cuy Agn o n offc o n of cnd Gn Ln Poy nd Cuy Agncy o Pon Ln Poy nd Cuy Agncy. CERTIFICATE FOR INSURANCE SERVICE REPRESENTATIVES Th o cfy h h bov-mnond cn ond o c n Inunc Svc Rnv (ISR) fo h Gn Ln Poy nd Cuy Agn/Agncy o Pon Ln Poy nd Cuy Agn/Agncy n h S of Tx, ubjc o h cn qufyng fo cn. If nd whn h onmn mnd o cncd, h Dmn mu b nofd mmdy of uch mnon. Th ISR Tnf/Cnc Emoymn Fom FIN529 my b found h gn g of Aonng Gn Ln Poy nd Cuy o Pon Ln Poy nd Cuy AGENT: (PRINT OR TYPE) SIGNATURE OF SPONSORING AGENT PRINT OR TYPE SPONSORING AGENT S LEGAL NAME AGENT S TDI LICENSE NUMBER (AS IT APPEARS ON THE CURRENT LICENSE) DATE SIGNED (MM/DD/YY) Aonng Gn Ln Poy nd Cuy o Pon Ln Poy nd Cuy AGENCY: (PRINT OR TYPE) SIGNATURE OF AGENCY OFFICER OR PARTNER SIGNING OFFICER S OR PARTNER S NAME SPONSORING AGENCY S LEGAL NAME (AS IT APPEARS ON THE CURRENT LICENSE) AGENCY S TDI LICENSE NUMBER DATE SIGNED (MM/DD/YY) P VI Noc of Aonmn - (Gn Ln Agn [GL], Lf Agn [LAGT], Lmd Ln Agn [LL],Fun P-ngmn Lf Agn[PN], Lf Inunc No Excdng $25,000 Agn[LI], Couny Muu Agn [CM], Mngng Gn Agn[MGA], Pon Ln Poy nd Cuy Agn[PLPC] nd Fu-Tm Hom Offc Sd Emoy [HOSE] Ony) Noc of Aonmn. To mk comny o ubgn onmn wh h cn con, h Noc of Aonmn fom on Pg 8 of 13 mu b gnd n nk by n uhozd onng offc of h onng INSURANCE COMPANY, AN EXECUTIVE OFFICER OR PARTNER OF THE SPONSORING AGENCY, OR THE SPONSORING INDIVIDUAL AGENT. Th fom w b jcd f do no conn h nd ogn gnu of h gnng nv. Th cn gnu w no b ccd. Th Noc of Aonmn mu ncud h d h fom gnd. A Noc of Aonmn do no y o Inunc Adju, Pubc Inunc Adju, Rk Mng, Suu Ln, Inunc Svc Rnv, o Lf nd Hh Inunc Couno Lcn. Tmoy Lcn. Ony cn fo Fun Pngmn Lf Agn, Lf Inunc No Excdng $25,000 Agn, o Couny Muu Agn Lcn my y fo moy cn wh h con. If moy cn qud by h onng comny nd f h comny nd cn gb, TDI w u uch cn fo od of 90 dy, whou xmnon. A moy cn my no b nwd o ud mo hn onc n concuv x-monh od o h m cn. A moy cn con mu ncud comd Noc of Aonmn. Th moy cn mu ovd o TDI cfcon by h onng nunc comny h h moy gn h comd h qud cou of udy nd d h wn xmnon wh Tx Dmn of Inunc 7/16

8 coy of h moy cn whn on y of h moy cn u d n od o obn h mnn cn whou nw con. A Rgon of Fu-Tm Hom Offc Sd Emoy con mu ncud comd Noc of Aonmn. Inunc Comny Aonmn. If comd Noc of Aonmn no cvd wh Gn Ln Agn, Lf Agn, Lmd Ln Agn, Fun Pngmn Lf Agn, Lf Inunc No Excdng $25,000 Agn, Couny Muu Agn, Mn- gng Gn Agn o Pon Ln Poy nd Cuy Agn Lcn con, h cn my b ud. Howv, no hn h 30h dy f h ffcv d of h gn onmn by h nunc comny, TDI Noc of Aonmn wh h $10.00 f mu b ubmd o TDI. Subgn Aonmn. ONLY GENERAL LINES AGENTS, PERSONAL LINES PROPERTY AND CASUALTY AGENTS AND LIFE AGENTS MAY APPOINT SUBAGENTS OR BE APPOINTED AS SUBAGENTS. A Gn Ln Lf, Accdn nd Hh Agn my on Gn Ln Lf Accdn nd Hh Agn o Lf Agn. A Lf Agn my on Gn Ln Lf Accdn nd Hh Agn o Lf Agn. A Gn Ln Poy nd Cuy Agn my on Gn Ln Poy nd Cuy Agn o Pon Ln Poy nd Cuy Agn. A Pon Ln Poy nd Cuy Agn my on Gn Ln Poy nd Cuy Agn o Pon Ln Poy nd Cuy Agn. Acn fo Lmd Ln, Fun Pngmn Lf, Lf Inunc No Excdng $25,000, Couny Muu, Mngng Gn Agn Lcn, o Fu-Tm Hom Offc Sd Emoy Rgon cnno b ond by n gncy o gn. NOTICE OF APPOINTMENT FOLLOWS ON THE NEXT PAGE Tx Dmn of Inunc 8/16

9 PLEASE FOLLOW INSTRUCTIONS ON PREVIOUS PAGE NOTICE OF APPOINTMENT FOR GL, LAGT, LL, PN, LI, CM, MGA, PLPC AND HOSE APPLICANTS FULL LEGAL NAME OF APPLICANT (PRINT OR TYPE)LAST NAME FIRST NAME MIDDLE NAME SUFFIX Ony ONE ono con. En comny, gncy o gn nfomon. Nm of Inunc Comny onng GL, LAGT, LL, PN, LI, CM, MGA, PLPC o HOSE cn: APPOINTING COMPANY NAME (GROUP NAMES NOT ACCEPTABLE) NAIC NUMBER OF APPOINTING COMPANY OR Nm of Agncy onong GL, LAGT o PLPC Subgn: SPONSORING AGENCY NAME (AS IT APPEARS ON THE CURRENT AGENCY LICENSE) AGENCY TAX ID NUMBER OR Nm of Indvdu Agn onong GL, LAGT o PLPC Subgn: SPONSORING AGENT NAME (AS IT APPEARS ON THE CURRENT AGENT LICENSE) SSN OF SPONSORING INDIVIDUAL AGENT Tmoy Lcn: (fo PN, LI, o CM cn y ony): Do h comny wn h bov nmd cn o cv moy cn o c fu-m gn n ccodnc wh h ovon of h Tx Inunc Cod? No Y If Y, ovd h hon numb of h offc wh h gn w b gnd: ( ) - Mngng Gn Agn: Th con mu b comd by n offc of h onng comny o c hvng on knowdg h h cn h hd xnc o nucon h woud qufy h cn mngng gn gn. W h bov mngng gn gn cn hv cm mn uhoy fo h comny o c? No Y Do h cm mn uhoy xcd $25,000 on ny on cm? No Y Do h cm mn uhoy ncud hd-y by oh hn oy dmg? No Y A fund xcdng $100,000 cuomy hd by h mngng gn gn fo h uo of yng o nd o djumn xn fo h comny o c? No Y Th Aonng Offc mu d nd gn h foowng mn: Th o cfy h h bov-mnond cn ond o c n gn fo h comny OR ubgn fo my gncy OR ubgn fo m n h S of Tx ubjc o h cn qufyng fo cn. If nd whn h onmn mnd o cncd, h Dmn w b nofd mmdy of uch mnon. Tx Dmn of Inunc 9/16

10 Th cn m h qumn ou n h Tx Inunc Cod nd h u nd guon omugd by h Tx Dmn of Inunc fo h y of cn d fo hn. I cknowdg my onby fo nung h h cn cv nng f qud by h Tx Inunc Cod. SIGNATURE OF APPOINTING OFFICIAL OF APPOINTING INSURANCE APPOINTING OFFICIAL S FULL LEGAL NAME AND COMPANY OR EXECUTIVE OFFICER OR PARTNER OF APPOINTING AGENCY OR OFFICER S OR PARTNER S FULL LEGAL NAME AND OR APPOINTING INDIVIDUAL AGENT OR INDIVIDUAL AGENT S FULL LEGAL NAME DATE SIGNED (MM/DD/YY) P VII Bckgound Infomon nd Fngn Th mu b comd by cn xc Emgncy Adju, Fu-Tm Hom Offc Sd Emoy, Pubc Inunc Adju nd Pubc Inunc Adju Tn gn. Pubc Inunc Adju cn cn nd n gon cn mu com P III nd k h. 1 I m dn of Tx nd:. I hv chd coy of my fngn c fom IdnoGo by Moho Tu USA o Pon VUE vdncng h my fngn hv bn ubmd o h Tx Dmn of Pubc Sfy ( g 12 fo com fngnng nucon) o b. I hv n cv TDI gn/dju cn nd I hv dy ubmd fngn o TDI o c. I hv n cv TDI cn o gon, oh hn n gn/dju cn, nd I hv dy ubmd my fngn o TDI wh TYPE OF APPLICATION OR FILING On. DATE FINGERPRINTS SUBMITTED TO TDI (MM/DD/YY) Rdn cn mu ncud coy of h fngn c un h cn (1) h n cv TDI cn o gon nd (2) ubmd fngn o TDI wh noh cn con o TDI fng. Fngn w b ud o chck cmn hoy cod of h Tx Dmn of Pubc Sfy nd h Fd Buu of Invgon n ccodnc wh cb u. 2 I m nondn of Tx, nd I m h bckgound nfomon qumn foow: (Adju Dgnd Hom S cn k o #3.). I hod n cv cn n good ndng n my dn fcd on h Non Aocon of Inunc Common Poduc Db o b. I m no n dju cn nd hv chd my cmn hoy cod h I hv cqud fom my dn w nfocmn gncy o c. I hv chd cun Cfc of Good Sndng fom my dn o d. I hv chd coy of my fngn c fom IdnoGo by Moho Tu USA o Pon VUE vdncng h my fngn hv bn ubmd o h Tx Dmn of Pubc Sfy.. I hod dgnd hom cn n good ndng n h foowng :. A nondn cn cn who do no hod cun nunc cn n good ndng n h cn of dnc h, hough h w nfocmn gncy of h of dnc, ubm coy of h cn cmn hoy cod. If h dn w no ovd cmn hoy cod fo cnng uo, h cn mu Tx Dmn of Inunc 10/16

11 ovd fngn c fom Moho Tu USA o Pon VUE vdncng h fngn hv bn ubmd o h Tx Dmn of Pubc Sfy ( g 12 fo com fngnng nucon). 3 I m nondn of Tx yng fo Dgnd Hom S Adju Lcn, nd I m dn of noh h do no cn dju fo h n of uhoy ough on g 1. I m h Tx fngn qumn by h o b o c, I hv ndcd bow.. I hv chd coy of my fngn c fom IdnoGo by Moho Tu USA o Pon VUE vdncng h my fngn hv bn ubmd o h Tx Dmn of Pubc Sfy ( g 12 fo com fngnng nucon) o b. I hv n cv TDI gn/dju cn nd I hv dy ubmd fngn o TDI o c. I hv n cv TDI cn o gon, oh hn n gn/dju cn, nd I hv dy ubmd my fngn o TDI wh, TYPE OF APPLICATION OR FILING on DATE FINGER PRINTS SUBMITTED TO TDI (MM/DD/YY) Tx Dmn of Inunc 11/16

12 P VIII Indvdu Acn Sgnu Pg (o b comd by cn) A Acn mu d, gn, nd hv h con nozd bfo ubmng h cn con. I hby cfy h I hv ony nwd ch of h quon hn nd h h nw u nd coc o h b of my knowdg nd bf. I fuh cfy h I m w of h ovon of h Tx Inunc Cod nd h u nd guon omugd by h Tx Dmn of Inunc whch o h unc of h cn fo whch I m yng nd h gound und whch uch cn my b dnd, undd, vokd o non-nwd, nd h I m h qumn fo h cn y d fo hn. I fuh cknowdg h I m ubjc o boh dcny con nd cmn ocuon f my con conn f, fcou, o fudun mn o ny wh gd o ny m fc. I undnd h fngn ovdd wh h con h b ud o chck cmn hoy cod of h Tx Dmn of Pubc Sfy nd h Fd Buu of Invgon n ccodnc wh cb u. I cknowdg nd undnd h I hv h duy o nfom h Common of Inunc of ny dcny con kn gn m n ny oh n whch I my b cnd whn hy (30) dy of h hnng of uch dcny con. I fuh cknowdg h I hv h duy o ud h nfomon connd on h con, ncudng chng of my dd, nd h fu o do o my conu gound fo vocon o unon of my nunc cn(). I undnd con ubjc o fuh vw. Any ffmv on o cnng quon my xnd ocng m. Fu o dco cmn hoy nfomon my u n dn of cn. SIGNATURE OF APPLICANT (PRINT OR TYPE BELOW) FULL LEGAL NAME OF APPLICANT LAST NAME FIRST NAME MIDDLE NAME SUFFIX Th S of, Couny of, Bfo m,, on h dy ony d (PRINTED NAME OF NOTARY PUBLIC), known o m (o ovd o m (PRINTED FULL LEGAL NAME OF APPLICANT) on h oh of o hough (PRINTED NAME OF WITNESS KNOWN TO NOTARY PUBLIC) (DESCRIPTION OF IDENTITY CARD OR OTHER DOCUMENT) o b h on who nm ubcbd o h fogong numn, nd cknowdgd o m h ()h xcud h m fo h uo nd condon hn xd. Gvn und my hnd nd of offc h (NOTARY SEAL) dy of, A.D. 20. (NOTARY PUBLIC SIGNATURE) Noy Pubc, S of Snd comd con, chck o mony od, md yb o h Tx Dmn of Inunc, nd oh qud documn o: Tx Dmn of Inunc, Agn nd Adju Lcnng MC 107-1A P.O. Box Aun, Tx Tx Dmn of Inunc 12/16

13 Gn Infomon LICENSE TYPE PART I PART II PART III PART IV PART V PART VI PART VII PART VIII Gn Ln LAH ( ) Gn Ln P&C ( ) Lf Agn (Ch 4054) Lf Inunc No Excdng $25,000 ( ) Fun Pngmn Lf ( ) Lf & Hh Inunc Couno (Ch 4052) Fu-Tm Hom Offc Sd Emoy ( ) Pon Ln Poy nd Cuy (Ch 4051) Lmd Ln ( nd ) Couny Muu ( ) Inunc Svc Rnv ( ) Mngng Gn Agn (Ch 4053) Suu Ln Agn (Ch 981) Rk Mng (Ch 4153) A A Pubc Inunc Adju (Ch 4102) Pubc Inunc Adju Tn (Ch 4102) m m Adju A Ln (Ch 4101) o o Adju P&C (Ch 4101) Adju Wok Com (Ch 4101) Adju Tn ( ) y y Adju Emgncy ( ) Adju A Ln Dgnd Hom S Tx (Ch 4101) Adju P&C Dgnd Hom S Tx (Ch 4101) c c Adju Wok Com Dgnd Hom S (Ch 4101) n n Rqud A moy cn vb fo h cn y. A P VI, Noc of Aonmn qud fo moy cn, ohw h Noc of Aonmn oon on h ogn con. Noc of Aonmn oon fo h y on n ogn con. Howv, no hn h 30h dy f h ffcv d of h gn onmn by n nunc comny, v o ubgn onmn by Gn Ln v gn/gncy, Noc of Aonmn wh h $10 f mu b ubmd o TDI, f h Noc of Aonmn no md on h con. If Noc of Aonmn no ubmd, hn comny cfcon mu b ovdd cfyng h cn h (1) comd cou of udy nd nucon nd (2) d whou d wn xmnon dmnd by h nu qud n h Tx Inunc Cod. Lcn y nfomon nd dcon, ncudng xmnon qumn nd xmon, my b found f f o o Th con wh f nd qud chmn mu b md o: Tx Dmn of Inunc, h h Agn nd Adju Lcnng MC 107-1A P O Box c c Aun TX n n Tx Dmn of Inunc 13/16 y y.. R q u d b R q u d b R q u d A m o y c n v b f o h c n y.

14 NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES Wh fw xcon, you nd o b nfomd bou h nfomon h h Tx Dmn of Inunc (TDI) coc bou you. Und con nd of h Tx Govnmn Cod, you hv gh o vw o cv co of nfomon bou youf, ncudng v nfomon. Howv, TDI my whhod nfomon fo on oh hn o oc you gh o vcy. Und con of h Tx Govnmn Cod, you nd o qu h TDI coc nfomon h TDI h bou you h ncoc. Fo mo nfomon bou h ocdu nd co fo obnng nfomon fom TDI o bou h ocdu fo cocng nfomon k by TDI, conc h Agncy Coun Scon of TDI Gn Coun Dvon (512) o v h Cocon Pocdu con of TDI wb F: 28 Tx Admnv Cod : A $50 con nd $150 moy cn con f nonfundb nd nonnfb uhozd by h Tx Inunc Cod. Mk chck o mony od yb o h Tx Dmn of Inunc. Acn wh Exd Lcn: If on cn h bn xd fo mo hn 90 dy bu hn on y, h on my no nw h cn, bu nd o nw cn whou kng h cb xmnon f h on ubm o TDI nw con, h cn f, nd n ddon f qu o on-hf of h cn f. If on cn h bn xd fo on y o mo, h on my obn nw cn by ubmng o xmnon, f xmnon qud fo ogn unc of h cn, nd comyng wh h qumn nd ocdu fo obnng n ogn cn. Gn Infomon (connud) Tmoy Lcn Acn: Ony cn yng fo Fun Pngmn Lf Lcn, Lf Inunc No Excdng $25,000 Lcn o Couny Muu Lcn my y fo moy cn wh h con. A oh moy cn cn mu ubm Pon VUE con fom o DSm Tchnoog, Foy Sx Pkwy, Su 2001, Sng Bnch, TX Th moy cn con mu ncud comd Noc of Aonmn, P VI, gnd by h onng comny. Th moy cn vd fo 90 dy f h d of unc. A moy cn hod mu ubm o h Dmn cfcon by h onng nunc comny h h moy gn h comd h cou of udy nd xmnon qud by h Tx Inunc Cod wh coy of h moy cn o obn mnn Fun Pngmn Lf Lcn, Lf Inunc No Excdng $25,000 Lcn o h Couny Muu Lcn. A moy cn my no b nwd o ud mo hn onc n concuv x-monh od o h m cn. Pubc Inunc Adju Tn Rgon A ubc nunc dju n gon x f 180 dy. A ubc nunc dju n who wh o obn ubc nunc dju cn mu h Pon VUE xmnon nd com h Pon VUE con nd ubm o DSm Tchnoog wh h qud $50.00 f. You my obn nfomon on h Pon VUE xmnon nd h Pon VUE con www. onvu.com/x /nunc Nondn Adju Dgnng Tx Rdn S Som do no cn dju. A dn of on of ho my obn Tx dju cn by mng Tx dn cn qumn nd hn dgnng Tx h hom fo h dju cn ony. Nondn Adju Dgnng Tx Rdn S mu comy wh h connung ducon qumn ound n Tx Inunc Cod nd 28 Tx Admnv Cod Nm: Acn mu uy h fu, g nm nd no ncknm. Fo nnc, Choh my no y Ch. Add: Th mng dd ovdd n P 1, numb 3 mu b you mnn mng dd nd h dd of cod o whch cn, offc coondnc, fom, noc nd oh nfomon w b n. Th cn/gn' cun mng dd umd o b h dd on h mo cn cn nw o cn con fom, whchv. Th dd w b condd h cn/gn' known dd fo h uo of noc o h cn/gn by TDI. Th g dn dd h dd wh you cuny v. Th Tx Dmn of Inunc 14/16

15 dn dd ud o dmn h of dnc fo cnng uo. Add chng mu b od o TDI qud n h Tx Inunc Cod nd If h mng, g dn o offc bun dd chng, h cn/gn onb fo nofyng TDI whn 30 dy, n wng, h by fx o: o by m o Tx Dmn of Inunc Agn nd Adju Lcnng M Cod 107-1A P O Box Aun TX You my obn h FIN533, Lcn Add Chng Rqu fom h, A dd chng qu mu b dd nd gnd by h cn hod. Pubc Inunc Adju Conc - Effcv Jnuy 1, 2014, conc qumn und mndd Tx Admnv Cod (TAC) , nd y o cnu of Pubc Inunc Adju (PIA). PIA conc mu b ubmd o TDI Agn nd Adju Lcnng offc fo ov wh n ogn con fo cn o con fo nw of PIA cn. Ao, conc wh ny modfcon o mndmn of m o condon mu b ubmd o TDI bwn cn nw. A Pubc Inunc Adju (PIA) cn my no b ud o nwd un h cn confm h h fom FIN535 o noh ovd conc fom w b ud onc cnd. Th conc you oo o u, onc cnd, mu b ubmd wh h ogn PIA cn con. Th fu by Pubc Inunc Adju o u oy uhozd nd ovd conc my u n unon, nonnw, vocon of h Pubc Inunc Adju cn, o oh dmnv ny (f. TAC (f)). Fngnng: Th fngn qumn uhozd n Tx Inunc Cod nd mndd 28 TAC nd Acn cmng xmon fom h fngn qumn bd on 28 TAC 1.504(b) mu ovd nfomon on h y of cn con o TDI fng wh whch h fngn w ubmd nd h d h fngn w ubmd o TDI. Th Tx Dmn of Inunc ongy ncoug cn o uz conc fngnng hough ovd vndo, uhozd und h u. Econc fngnng f nd ccu, nd n mo c w vod on dy n h ocng of you ubmon. Fngn cd no ong ccd by TDI. P Excon o Econc Fngnng bow whn no ob fo you o g concy fngnd. Econc Fngnng: Th gn oc fo conc fngnng : 1 Pn nd com h FAST P fom fom TDI wb, You w nd nfomon fom h FAST P fom o mk you conc fngn onmn. 2 Schdu n onmn o b concy fngnd. You mu chdu fngn onmn by vng o by cng Puun o DPS qumn on h vndo, you w b hooghd of h fngn oc. You mu y h $39.70 f o h vndo n mnn h ccb o h vndo. A conc fngn onmn mu b md by DPS vndo, Moho Tu Tx Dmn of Inunc 15/16

16 USA. Th vndo h mny Tx fngn ocon, ncudng h Pon VUE ng cn whch dmn h TDI gn/dju cnng xmnon. S h FAST P fom fo com nucon o obn n conc fngn onmn. 3 Av you chdud onmn wh you FAST P. Af you fngn nd hoogh kn, h chncn w gv you c ng h you w fngnd. Do no how wy h c. You w no g nd fngn cd. You fngn w b n concy o DPS nd h FBI. 4 Ach coy of h fngn c o you con. A FAST P c mu b chd o you con f you qud o ovd fngn. K h ogn FAST P c fo you cod. Excon o Econc Fngnng: Whn conc fngnng no vb, h foowng oc mu b foowd. 1 Pn nd com h FAST Fngn Cd Scn Auhozon Fom fom TDI wb, ALL nfomon qud on h FAST Fngn Cd Scn Auhozon Fom MUST b ovdd. 2 G fngnd by cmn w nfocmn gncy on n ogn APPLICANT fngn cd h ncud Tx Dmn of Inunc ORI TX920540Z. ALL qud nfomon mu b ovdd on h fngn cd nd you nd h offc kng h fngn mu gn h cd. Bnk cd my b obnd fom TDI by cng o -m qu o Lcn LICENSE@d.x.gov. A fngn MUST b cud by w nfocmn gncy. 3 Mk chck fo $39.70 yb o Moho Tu USA. 4 M h comd Fngn Cd Scn Auhozon Fom, ogn fngn cd nd chck o: Moho Tu USA An: Tx Cd Scn 3051 Ho Dv, Su 310 Sngfd, IL W fo FAST c fom Moho Tu USA. Th FAST c mu b chd o h comd Acon fo Indvdu Agn Lcn h m md o h Tx Dmn of Inunc. Th FAST c ow TDI o oc cmn hoy nfomon on h ndvdu. Fngn ovdd fo h con h b ud o chck cmn hoy cod of h Tx Dmn of Pubc Sfy nd h Fd Buu of Invgon, n ccodnc wh cb u. TDI cnno com ocng n con un cv cmn hoy o fom DPS nd FBI fo cn qud o ovd fngn c. Rfnc: You my vw h Tx Inunc Cod h:// nd h Tx Admnv Cod h://xg.o..x.u/ubc/dc$x.vwc. Tx Dmn of Inunc 16/16