Cal. Code Regs. Tit. 10, § 2194.16 - Forms | State Regulations | US Law

(a) Form 441-9 for individuals.

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NOTICE: INFORMATION COLLECTION AND ACCESS

Section 1798.17 of the California Civil Code requires the following information to be provided when collecting information from individuals to determine compliance with the group and corporate practice provisions of the law, and to establish positive identification, to match the names of the certified list provided by the Department of Child Support Services to applicants and licensees, and of responding to requests for this information made by child support agencies.

AGENCY: Department of Insurance ADDRESS: 320 Capitol Mall, Sacramento, CA 95814-4309 TELEPHONE NUMBER: (800) 967-9331 or (916) 322-3555

TITLE OF OFFICIAL RESPONSIBLE FOR INFORMATION MAINTENANCE: Chief, Producer Licensing Bureau

AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE INFORMATION: California Insurance Code, Chapters 5, 6, 7, 8-Part 2, Division 1

THE CONSEQUENCES, IF ANY, OF NOT PROVIDING ALL OR PART OF THE REQUESTED INFORMATION: It is mandatory that you provide all information requested. Omission of any item of requested information will result in the application being rejected as incomplete.

THE PRINCIPAL PURPOSE(S) FOR WHICH THE INFORMATION IS TO BE USED: The information requested will be used to determine qualifications for licensure or certification, to determine compliance with the group and corporate practice provisions of the law and to establish positive identification.

EACH INDIVIDUAL HAS THE RIGHT TO REVIEW OWN PERSONAL FILES MAINTAINED BY THE AGENCY SUBJECT TO ANY LIMITATIONS UNDER THE INFORMATION PRACTICES ACT OF 1977, CIVIL CODE SECTION 1798.40, AND EXEMPTIONS UNDER THE CALIFORNIA PUBLIC RECORDS ACT, GOVERNMENT CODE SECTION 6254 .

INSTRUCTIONS FOR COMPLETING APPLICATION

RE: "LICENSE TYPE" a separate application is required for each license type requested

RE: "APPLICANT NAME" Enter full legal name. If no middle name, enter (NMN). If any part of your legal name is an initial only, place parentheses around such initial.

RE: "ADDRESS INFORMATION" Do not enter the word "same" in any address area. Enter the appropriate address. P. O. BOX is not acceptable for a resident or business address. Business and mailing addresses are public record and are available to the public. It is the applicants/licensees responsibility to notify the department of any change in address.

RE: "ARE YOU A CITIZEN OF THE UNITED STATES" If no is answered, the applicant must supply a copy of both sides of the work authorization.

RE: "EXAM INFORMATION" Examinations are administered daily, Monday through Friday at 8:30 a.m. and 1:00 p.m., in Los Angeles (LA), San Diego (SD), San Francisco (SF) and Sacramento (SA). An examination is also administered twice monthly in Clovis usually the second and fourth Saturday of the month at 8:30 a.m. If you fail to appear for a scheduled examination, an additional examination fee will be required for rescheduling.

RE: "PREVIOUS LICENSE HISTORY INFORMATION" If currently licensed as a resident in another state, upon becoming a California resident, a clearance letter from the previous state of residence is also required.

RE: "AKA/ALIAS" List previously and currently used aliases and maiden names, if any. If you are currently using an "also known as" (AKA) name which you desire to be noted on record, so state. Abbreviations of true name or "nick" names are not acceptable.

RE: "BACKGROUND QUESTIONS" If you answer yes to any of these questions, you must submit a signed statement, with your original signature summarizing the details of each event. You must also provide the additional certified documentation described with each question.

PRELICENSING EDUCATION REQUIREMENTS: Effective 1/1/92 all new applicants must:

A) take an approved minimum 40-hour class for the fire and casualty broker-agent license exam, and/or;

B) take an approved minimum 40-hour class for the life agent license exam, and/or;

C) take an approved minimum 20-hour class for the personal lines broker-agent license exam,

D) and take an approved minimum 12-hour class on ethics and the California Insurance Code.

An applicant will be taking either 52 hours (40 and 12) or 92 hours (40 and 40 and 12) of prelicensing class hours depending on whether one or both licenses are being sought. The Personal Lines Broker-Agent applicant is required to complete 32 hours (20 and 12) of prelicensing classroom hours. Original certificates must be signed and submitted with the application.

ADDITIONAL FILING REQUIREMENTS:

The following documents are required to be submitted with the application for the specific license types as listed:

MC - Action Notice of Appointment (Form 447-54A (Rev. 03/2006)) from the sponsoring insurance company.

SL - $50,000 bond (Form 447-31 (Rev. 1/2003)) with a properly executed Power of Attorney form attached.

SP - $10,000 bond (Form 447-32 (Rev. 1/2003)) with a properly executed Power of Attorney form attached.

CS - $10,000 bond (Form 447-70 (Rev. 12/2003)) with a properly executed Power of Attorney form attached.

CI - Action Notice of Appointment (Form 447-54A (Rev. 03/2006)) from the sponsoring insurance company and/or Business Entity Endorsement (Form 411-8A (Rev. 12/2003)) completed by sponsoring Business Entity.

The following documents may be submitted with the initial application. Submitting these documents at a later date will not delay the issuance of your license, however, no authority to transact insurance will be granted until such time as the document has been received. If submitting an online application, these documents are to be submitted after your license is issued:

PF - Action Notice of Appointment (Form 447-54A (Rev. 03/2006)) from the sponsoring fraternal benefit society or association admitted to California.

LX - Action Notice of Appointment (Form 447-54A (Rev. 03/2006)) from the sponsoring insurance company and/or; Business Entity Endorsement (Form 411-8A completed by sponsoring business entity. To be granted variable authority acceptable proof of registration with SECO or NASD must be submitted with application and you must be appointed by an insurer authorized for variable contracts. Failure to submit proof of registration will result in license being issued without variable authority.

TA -Action Notice of Appointment (Form 447-54A (Rev. 03/2006)) from the sponsoring insurance company.

FX/PL - License authority is determined by what documents are submitted. To act as a:

BROKER - $10,000 bond (Form 417-5 (Rev. 10/2002)) with properly executed Power of Attorney form attached and/or Business Entity Endorsement (Form 411-8A (Rev. 12/2003)) completed by sponsoring Business Entity.

AGENT - Action Notice of Appointment (Form 447-54A (Rev. 03/2006)) from the sponsoring insurance company and/or Business Entity Endorsement (Form 411-8A (Rev. 12/2003)) completed by sponsoring Business Entity.

SOLICITOR - Action Notice of Solicitor (Form 417-31 (Rev. 7/95)) completed by the sponsoring insurance agent or broker.

> To obtain insurance licensing FORMS by mail, send request to: Department of Insurance, 320 Capitol Mall, Sacramento, CA 95814, or you may phone Sacramento toll free at (800) 967-9331 or (916) 322-3555, press 3. Forms are also available on our Web site at http://www.insurance.ca.gov

> To obtain insurance licensing information, you may phone our Sacramento office toll free at (800) 967-9331 or (916) 322-3555. You may also obtain licensing information and a complete list of licensing fees by visiting our Web site at http://www.insurance.ca.gov

>

>	MAIL APPLICATION WITH ATTACHMENTS AND FEES TO:	DEPARTMENT OF INSURANCE
		P. O. BOX 1139
		SACRAMENTO, CA 95812-1139

(b) Form 441-11 for organizations.

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NOTICE: INFORMATION COLLECTION AND ACCESS

Section 1798.17 of the California Civil Code requires the following information to be provided when collecting information from individuals to determine compliance with the group and corporate practice provisions of the law, and to establish positive identification, to match the names of the certified list provided by the Department of Child Support Services to applicants and licensees, and of responding to requests for this information made by child support agencies.

AGENCY: Department of Insurance ADDRESS: 320 Capitol Mall, Sacramento, Ca 95814-4309 TELEPHONE NUMBER: (800) 967-9331 or (916) 322-3555

TITLE OF OFFICIAL RESPONSIBLE FOR INFORMATION MAINTENANCE: Chief, Producer Licensing Bureau

AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE INFORMATION: California Insurance Code, Chapters 5, 6, 7, 8-Part 2, Division 1

THE CONSEQUENCES, IF ANY, OF NOT PROVIDING ALL OR PART OF THE REQUESTED INFORMATION: It is mandatory that you provide all information requested. Omission of any item of requested information will result in the application being rejected as incomplete.

THE PRINCIPAL PURPOSES (S) FOR WHICH THE INFORMATION IS TO BE USED: The information requested will be used to determine qualifications for licensure or certification, to determine compliance with the group and corporate practice provisions of the law and to establish positive identification.

EACH INDIVIDUAL HAS THE RIGHT TO REVIEW OWN PERSONAL FILES MAINTAINED BY THE AGENCY SUBJECT TO ANY LIMITATIONS UNDER THE INFORMATION PRACTICES ACT OF 1977, CIVIL CODE SECTION 1798.40, AND EXEMPTIONS UNDER THE CALIFORNIA PUBLIC RECORDS ACT, GOVERNMENT CODE SECTION 6254.

* INSTRUCTIONS FOR COMPLETING BUSINESS ENTITY APPLICATION

RE: "BUSINESS ENTITY TYPE":

CORPORATION - if already incorporated, attach a copy of your Certificate of Good Standing. If corporation has been formed as a result of a merger, submit a copy of your approved merger papers.

PARTNERSHIP - attach a copy of the partnership agreement (if any). If no agreement, so state on application. The PARTNERSHIP'S FEDERAL IDENTIFICATION NUMBER IS MANDATORY and must be entered in the space shown.

LIMITED LIABILITY COMPANY - attach a copy of your approved articles of organization. Additional requirements are listed on page 4. This documentation must be submitted with your application.

RE: "BUSINESS ENTITY NAME":

The true business entity name must be entered. Include commas, hyphens, ampersands, etc. This name is subject to disapproval by the Insurance Commissioner.

RE: "FICTITIOUS NAME":

If you intend to transact insurance in a name other than the true business entity name, enter such fictitious name. This name is subject to disapproval by the Insurance Commissioner.

RE: "DESIGNATED/RESPONSIBLE LICENSED PRODUCER":

You must list all licensed producers intending to transact on behalf of the business entity. All unlicensed producers intending to transact on behalf of the business entity must complete form 441-9.

RE: "CONTROLLING PERSON":

Insurance Code Section 1668.5(b), in part, defines a "controlling person" as a person who possesses the power to direct or cause the direction of the management and policies of the business entity.

RE: "BACKGROUND INFORMATION":

If the answer is "yes" to any of these questions, you must submit required documentation.

RE: "APPLICANT'S CERTIFICATION":

Partnership - each partner of the partnership must sign. Corporation or Association - an officer having authority to bind the Corporation or Association must sign.

______

FEES

______

A) Licenses are issued for a two-year term, which begins the date the first license is issued to the business entity and ends the last day of that calendar month two years later. Subsequent licenses are issued for the balance of the established license term.

B) Fees: Filing fees are required for each business entity application submitted, except that Surplus Line or Special Lines' fees may vary - see below:

SURPLUS AND SPECIAL LINES' FILING FEES:

1) One filing fee covers the first TWO natural persons named under either of these license types. An additional filing fee is required for each subsequent natural person to be named on the license.

2) Fees collected from one person for either the Surplus Line or Special Lines' license cover that person's fees for both licenses.

C) Total fee due is determined by adding the appropriate filing fees in (A) and (B) above to other applicable fees listed in enclosed fee chart.

> PLEASE REVIEW THE APPLICATION CAREFULLY AFTER COMPLETION. ANY OMISSIONS OR DEFICIENCIES WILL RESULT IN A DELAY IN THE PROCESSING OF YOUR APPLICATION FOR LICENSE.

>	MAIL APPLICATION WITH FEES TO:	DEPARTMENT OF INSURANCE
		P. O. BOX 1139
		SACRAMENTO, CA 95812-1139

> DIRECT QUESTIONS REGARDING THIS FILING TO THE PRODUCER LICENSING BUREAU IN SACRAMENTO, (800) 967-9331 or (916) 322-3555

> ALL FEES ARE FILING FEES AND ARE NOT REFUNDABLE OR TRANSFERABLE, WHETHER OR NOT THE APPLICATION IS ACTED UPON OR THE EXAMINATION TAKEN.

(c) Form Lic. SSA 1.

The list of authorized endorsees shall be made on Form Lic. SSA 1. The list shall be maintained in a format capable of transmission to the Commissioner or a designee of the Commissioner electronically and in hard copy or diskette, however requested by the Commissioner or a designee of the Commissioner pursuant to Section 2194.15(c) above. The electronic version shall be transmitted in commercial word-processing or spreadsheet form. When requested, the list shall be updated to include endorsees newly authorized up to thirty (30) days before the mailing date of the request, and shall include the dates upon which each endorsee's authorization began and, if relevant, terminated. It shall then be transmitted as an attachment to the e-mail or by regular mail in hard copy or diskette, as requested.

The appropriate e-mail or regular mailing addresses shall be posted by the Department on its website at http://www.insurance.ca.gov.

Authorized Endorsees--Self-Service Storage Facility Form Lic. SSA 1

Producer Licensing Bureau

P.O. Box 1139

Sacramento, CA 95812-1139

Information: (800) 967-9331 Or (916) 322-3555

www.insurance.ca.gov

California Department of Insurance

Self-Service Storage Agent

Authorized Endorsees

Pursuant to CIC Section 1758.72(d)

Effective Date:_______________

The listed endorsees, having met the training requirements of California Insurance Code Section 1758.72(a) are authorized to offer the following types of insurance in connection with the rental of self-service storage space.

1. Hazard insurance providing coverage to renters for the loss of, or damage to, tangible personal property in storage or in transit during the rental period, only in connection with and incidental to, self-service storage rental agreements.

Note: This form must be completed annually and maintained for a three year period pursuant to CIC section 1758.72(d)

Producer Licensing Bureau

P.O. Box 1139

Sacramento, CA 95812-1139

Information: (800) 967-9331 Or (916) 322-3555

www.insurance.ca.gov

California Department of Insurance

Self-Service Storage Agent

Authorized Endorsees

Pursuant to CIC Section 1758.72(d)

Location	Manager	Name of Employee(s)	Employee ID

(d) Form Lic. SSA 2.

The insurer certification shall be made on Form Lic. SSA 2.

Notice of Appointment--Self-Service Storage Facility

Form Lic. SSA 2

Producer Licensing Bureau

P.O. Box 1139

Sacramento, CA 95812-1139

Information: (800) 967-9331 Or (916) 322-3555

www.insurance.ca.gov

SELF-SERVICE STORAGE AGENT NOTICE OF APPOINTMENT

To California Insurance Commissioner

Pursuant to CIC Section 1758.71(a)(2)

Insurer Name: ______________________________

FEIN: ___________________________		NAIC # ___________________________	CA Company # ___________________________
Federal Employer Identification Number

To the Insurance Commissioner of the State of California: Notice is hereby given that effective from the date shown on this notice, the designated insurer hereby appoints the self-service storage facility named herein to act as its agent and certifies that it has satisfied itself that the named self-service storage facility is trustworthy and competent to act as its self-service storage agent.

Name of Self-Service Storage Facility ________________________________________

Social Security # / FEIN # ______________________________

(*Mandatory pursuant to Cal. Ins. Code § 1666.5; Cal. Civil Code § 1798.17; Cal. Family Code § 17520(d); and Federal Privacy Act of 1974 §§ 7(a)(2)(B) and 7(b).)

Effective Date ______________________________

CIC Section 1758.71 (a)(2) requires that an applicant for a self-service storage agent license under this article shall file with the commissioner a certificate by the insurer that is to be named in the self-service storage agent license, stating that the insurer has satisfied itself that the named applicant is trustworthy and competent to act as its insurance agent limited to this purpose and that the insurer will appoint the applicant to act as its agent to transact the kind or kinds of insurance that are permitted by this article, if the self-service storage agent license applied for is issued by the commissioner.

Section 1798.17 of the California Civil Code requires the following information to be provided when collecting information from individuals to determine compliance with the group and corporate practice provisions of the law, and to establish positive identification, to match the names of the certified list provided by the Department of Child Support Services to applicants and licensees, and of responding to requests for this information made by child support agencies.

I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. This is executed on the _______________ day of ____________________, _______________.

Signature of insurer or managing agent of insurer: Signature must be that of an officer of the Company, managing agent, or a person authorized under a Special Power of Attorney on file with the Department.

___________________________
Name (print)	Official Title (print)	Date

Phone Number ( )_______________

_________________________

Name of Insurer or managing agent

(print)

By: _________________________

(signature)

(e) Form Lic. SSA 3.

Training materials submitted to the Commissioner shall contain all of the elements set forth in Form Lic. SSA 3.

Required Training Elements--Self-Service Storage Facility

Form Lic. SSA 3

Producer Licensing Bureau

P.O. Box 1139

Sacramento, CA 95812-1139

Information: (800) 967-9331 Or (916) 322-3555

www.insurance.ca.gov

California Department of Insurance

Self-Service Storage Agent

Outline of Required Training Elements

California Insurance Code Section 1758.72(a) requires all self-service storage agents to provide an insurance training program for its employees that shall meet specified minimum requirements. In an effort to assist you with developing your training program, we have provided you with the following checklist of required training elements to be covered in your materials.

1. Section 1758. 72(a)(1) requires that each employee receive instruction about the types of insurance specified in Section 1758.75, as follows, that are offered for sale to prospective renters.

Y Insurance that provides hazard insurance coverage to renters for the loss of, or damage to, tangible personal property in storage or in transit during the rental period, and only in connection with, and incidental to, self-service storage rental agreements.

2. Section 1758.72(a)(2) requires that each employee receive training about ethical sales practices. Pursuant to 1758.78 a self-service storage agent shall not do any of the following:

[TICK] Offer to sell insurance except in conjunction with, and incidental to, authorized rental agreements.

[TICK] Advertise, represent, or otherwise portray itself or its employees as licensed insurers, insurance agents, or insurance brokers.

Section 1758.76 (a) states that a licensee shall not sell insurance pursuant to this article unless all of the following conditions are satisfied: The self-service agent provides brochures or other written material to the prospective renter that does all of the following:

[TICK] Summarizes the material terms and conditions of coverage offered to renters, including the identity of the insurer.

[TICK] Describes the process for filing a claim, including a toll-free telephone number to report a claim.

[TICK] Discloses any additional information on the price, benefits, exclusions, conditions, or other limitations of the types of insurance specified in 1758.75 that the commissioner may by rule prescribe in regulation.

[TICK] Provide the licensee's name, address, telephone number, and license number and the availability of the department's toll-free consumer hotline.

3. Section 1758.72(a)(3) requires that each employee receive training about the disclosures to be given to prospective renter pursuant to subdivision (b) of Section 1758.76. The self-service storage agent makes all of the following disclosures to the renter, which shall be acknowledged in writing by the renter, or displayed by clear and conspicuous signs that are posted at every location where rental agreements are executed, such as the counter where a renter would sign a rental agreement:

[TICK] That the purchase by the renter of the insurance is not required in order to rent storage space. However, the licensee's employees may advise the renter that the self-service storage facility's rental agreement may contain provisions requiring the renter to provide insurance on his or her property in the storage unit.

[TICK] That the insurance policies offered by the self-service storage agent may provide a duplication of coverage already provided by a renter's homeowners insurance policy or by another source of coverage.

[TICK] That the self-service storage facility and its employees are not qualified or authorized to evaluate the adequacy of the purchaser's existing coverage.

[TICK] That if a renter elects to purchase the coverage, evidence of coverage must be stated on the face of the rental agreement or must be provided to the renter.

[TICK] That the insurance is provided under an individual, a group, or a master policy issued to the self-service storage agent by an insurer authorized to write the types of insurance specified in Section 1758.75 in this state.

(f) All forms set forth in their entirety in this section are available upon request, by telephone or in writing to the Department of Insurance or on the website of the Department of Insurance at www.insurance.ca.gov.

Cal. Code Regs. Tit. 10, § 2194.16 - Forms

Notes