If yes, attach an original clearance letter from prior state dated within 90 days.
CITIZENSHIP AFFIDAVIT FORM GID 276 EN LICENSE
Have you held an insurance license of any type in any other state within the last 5 years? If yes, list license type, number and last year licensed. Have you ever held an insurance license issued by this department? If yes, attach supplement indicating the type of license, reason for withdrawal and the licensing authority.ĭo you or will you maintain an office as an insurance agent, adjuster, counselor, limited subagent or surplus lines broker in this state? Have you ever withdrawn an application for any business or professional license granted by any licensing authority?
CITIZENSHIP AFFIDAVIT FORM GID 276 EN FULL
If yes to any of the above, attach supplement giving full details and attach certified copies of all orders. Failed to notify the Insurance Commissioner in writing within sixty days of the occurrence of any event listed above. Had the renewal of any license, permit, authorization, registration, or privilege refused by any authority pursuant to aĭisciplinary proceeding other than that of the Insurance Commissioner.ĭ. Had any other disciplinary action taken against you?Ĭ. Had any license, permit, authorization, registration, or privilege denied, refused, revoked, suspended, limited, withdrawn,ī. Have you ever had any other administrative action instituted against you by the insurance regulatory authority of any state?Ī. If yes, attach supplement giving full details and attach certified copies of all orders. Have you ever been refused or had suspended or revoked an insurance license in any state? If yes, attach a supplement giving full details and attach certified copies of plea agreements and all court orders. Have you received first offender treatment or had adjudication of guilt withheld in a criminal proceeding, other than a minor traffic offense? Have you been convicted of or are you currently charged with the commission of any crime or pled nolo contendere in a criminal proceeding or If yes, attach certified copies of ALL plea agreements and court orders. Have you ever been convicted of or are you currently charged with a felony? If yes, attach a letter from the insurer/agent to whom you are indebted giving full details.
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