COVER SHEET NATION MOTOR CLUB, INC DBA NATION SAFE DRIVERS North Carolina Motor Club Representative Appointment Procedure The State of North Carolina requires all motor club representatives to be licensed and appointed to produce motor club business. The licensing/appointment process is the same for both resident and non-resident representatives. Nation Safe Drivers will require the following information in order to process a motor club licensing and appointment. Representative already licensed for Motor Club- Need an appointment only: п‚· Completed Representative/Producer Questionnaire п‚· A clear copy of the Limited Representative License (with Motor Club line of authority) п‚· $20.00 appointment fee New Motor Club Representative Licensing: п‚· Completed NAIC Application п‚· Representatives already holding a North Carolina producers license will only need to add motor club as a line of authority to the current license. The fee for licensing & appointment is $125.00 п‚· To obtain a new limited representative motor club license without any prior licensing in North Carolina, the fee is $163.00 (this includes a background check fee of $38.00 as required by the state of North Carolina). OR п‚· An application can apply online at www.nipr.com for his/her Limited Representative License, and then submit a copy of the new license to Nation Safe Drivers along with a completed Representative Questionnaire Form and $20 appointment fee. ***NEW UPDATES *** All new Resident Producers must complete background check forms for the North Carolina Department of Insurance. Please visit the website at http://www.ncdoi.com/asd/asd_publications.asp . Effective June 1, 2012 the State of North Carolina has also had a fee increases due to the outsourcing of license administrative services to Pearson VUE. Additional information on license administration outsourcing is available on the department's website www.ncdoi.com under Agent Services Division Hot Topics. The new fee increases have affected all types of licenses. Annual renewal April 30th Renewal fee $20 Feel free to contact us with any questions at 800-338-2680 ext. 516 or at compliance@nationsafedrivers.com Make Checks payable to Nation Safe Drivers and mail both the check and all completed forms to: Nation Safe Drivers Licensing & Compliance Department 800 Yamato Road, Suite 100 Boca Raton, Florida 33431 Revised 07/10/2012 Nation Motor Club, Inc. 800 Yamato Road Suite 100, Boca Raton, FL 33431 Tele: 561-226-3600/Fax 561-226-3608 REPRESENTATIVE/PRODUCER QUESTIONNAIRE 1. Full name of applicant ________________________________________________________________ (First Name) (Middle) (Last) 2. Resident Address ____________________________________________________________________ (Physical Street) (City) (State, Zip) 3. Home Telephone Number (_______)_________________ 4. Social Security Number __ __ __ - __ __ - __ __ __ __ 5. Date of Birth ________________________ 6. Property & Casualty License Number (If Applicable)________________________________________ 7. Business Name and Address ___________________________________________________________ _____________________________________________________________________________________ (Physical Street) (City) (State, Zip) 8. FEIN _________________________________________________ 9. Business Telephone Number (_______)__________________ 10. Business Fax Number (_______)_________________ 11. Email Address _____________________________________________________________________ I hereby verify my foregoing statements and answers and declare under penalties of perjury that they are correct. This _____ day of __________, 20______ ___________________________________ ( Appl i c a nt вЂ™ sSi g na t ur e ) Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com. Uniform Application for Individual Producer License/Registration (Please Print or Type) Check appropriate box for license requested. пЃ± Resident License пЃ± Non-Resident License вЂў Identify Home State: ____________________ в—Џ Demographic Information 1 Soc. Security Number 2 3 If assigned, National Producer Number (NPN) - If applicable, FINRA Individual Central Registration Depository (CRD) Number 4 Last Name JR./SR. etc 5 First Name 7 Date of Birth 6 Middle Name (month) ___ (day) ___ (year)____ 8 Residence/Home Address (Physical Street) 13 Home Phone Number 9 City Gender (Circle One) Male Female 14 ( ) Individual Applicant Email Address: в—Џ 10 State 11 Zip Code 12 Foreign Country 15 Are you a Citizen of the United States? (Check One) Yes в—Џ No (If No, of which country are you a citizen?) (If NO, and this is an application for a Resident License, you must supply proof of eligibility to work in the U.S.) 16 Business Entity Name 17 Business Address (Physical Street) 23 Business Phone Number (include 18 P.O. Box 24 Business Fax Number extension) ( ) 27 ApplicantвЂ™s Mailing Address ( ) 19 City 20 State 21 Zip Code 25 Business E-Mail Address 22 Foreign Country 26 Business Web Site Address 28 P.O. Box 29 City 30 State 31 Zip Code 32 Foreign Country 33 a. List any other assumed, fictitious, alias, maiden or trade names which you have used in the past. b. List any trade names under which you are currently doing business or intend to do business. (May be subject to state approval) Agency or Business Entity Affiliations 34 List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity) FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________ FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________ FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________ Employment History 35 Account for all time for the past five years. Give all employment experience starting with your current employer working back five years. Include full and part-time work, self-employment, military service, unemployment and full-time education. From Month Name City State Foreign Country State Foreign Country State Foreign Country State Foreign Country Name City Name City Name City (State Use) В© 2011 National Association of Insurance Commissioners Page 1 of 5 Year To Month Year Position Held Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com. Uniform Application for Individual Insurance Producer License/Registration Jurisdiction and Type of License Requested 36 Next to each jurisdiction, check the license type(s) and line(s) of authority for which you are applying. License Types: A вЂ“ Agent B вЂ“ Broker P - Producer SLP вЂ“ Surplus Lines Producer P вЂ“ Property C вЂ“ Casualty T вЂ“ Travel S вЂ“ Surety Lines of Authority: V вЂ“ Variable Life/Variable Annuity L вЂ“ Life H вЂ“ Accident & Health or Sickness Limited Lines: CreditвЂ“ Credit CR вЂ“ Car Rental CROP - Crop License Type Jurisdiction AK AL AR A B P Major Lines of Authority SLP V L H P C AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VI VA VT WA WI WV WY В© 2011 National Association of Insurance Commissioners Page 2 of 5 PL Credit CR PL вЂ“ Personal Lines O вЂ“ Other: Specify Type Limited Lines of Authority CROP T S O ___________ Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com Uniform Application for Individual Insurance Producer License/Registration Background Information 37 The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must include an original signature. 1. Have you ever been convicted of a crime, had a judgment withheld or deferred, or are you currently charged with committing a crime? в—Џ No___ Yes ___ Note: вЂњCrimeвЂќ includes a misdemeanor, a felony or a military offense. You may exclude misdemeanor traffic citations and misdemeanor convictions or pending misdemeanor charges involving driving under the influence (DUI) or driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license and juvenile offenses. вЂњConvictedвЂќ includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine. If you answer yes, you must attach to this application: a) a written statement explaining the circumstances of each incident, b) a copy of the charging document, c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment. If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of в—Џ insurance in your home state as required by 18 USC 1033? N/A_____ Yes_____ No _____ If so, was consent granted? (Attach copy of 1033 consent approved by home state.) в—Џ Yes ____ No _____ N/A _____ 2. Have you ever been named or involved as a party in an administrative proceeding, including FINRA sanction or arbitration proceeding regarding any professional or occupational license or registration? в—Џ No___ Yes ___ вЂњInvolvedвЂќ means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license to resolve an administrative action. вЂњInvolvedвЂќ also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. вЂњInvolvedвЂќ also means having a license, or registration application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of your actions,in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee. If you answer yes, you must attach to this application: a) a written statement identifying the type of license and explaining the circumstances of each incident, b) a copy of the Notice of Hearing or other document that states the charges and allegations, and c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment. 3. Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others в—Џ No___ Yes ___ If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and location of bankruptcy. 4. Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement? в—Џ No___ Yes ___ If you answer yes, identify the jurisdiction(s): _______________________________________ 5. Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? If you answer yes, you must attach to this application: a) a written statement summarizing the details of each incident, b) a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or mediation proceedings, and c) a copy of the official documents, which demonstrates the resolution of the charges or any final judgment. В© 2011 National Association of Insurance Commissioners Page 3 of 5 в—Џ No___ Yes ___ Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com. Uniform Application for Individual Insurance Producer License/Registration 6. Have you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct? в—Џ No___ Yes ___ If you answer yes, you must attach to this application: a) a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license, and b) copies of all relevant documents. в—Џ No___ Yes ___ 7. Do you have a child support obligation in arrearage? If you answer yes, a) by how many months are you in arrearage? b) are you currently subject to and in compliance with any repayment agreement? c) are you the subject of a child support related subpoena/warrant? (If you answered yes, provide documentation showing proof of current payments or an approved repayment plan from the appropriate state child support agency.) 8). In response to a вЂњyesвЂќ answer to one or more of the Background Questions for this application, are you submitting document(s) to the NAIC/NIPR Attachments Warehouse? If you answer yes вњ” N/A ___ в—Џ No___ Yes ___ в—Џ No___ Yes ___ Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application? Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed with this application, you must go to the Attachments Warehouse and associate (link) the supporting document(s) to this application based upon the particular background question number you have answered yes to on this application. You will receive information in a follow-up page at the end of the application process, providing a link to the Attachment Warehouse instructions. В© 2011 National Association of Insurance Commissioners _________Months Yes ___ No___ в—Џ в—Џ Yes ___ No___ Page 4 of 5 Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com. Uniform Application for Individual Insurance Producer License/Registration ApplicantвЂ™s Certification and Attestation 38 The Applicant must read the following very carefully: 1. 2. 3. 4. 5. 6. 7. 8. I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of the license and may subject me to civil or criminal penalties. Unless provided otherwise by law or regulation of the jurisdiction , I hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to be my agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction is of the same legal force and validity as personal service upon myself. I further certify that I grant permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company. I further certify that, under penalty of perjury, a) I have no child-support obligation, b) I have a child-support obligation and I am currently in compliance with that obligation, or c) I have identified my child support obligation arrearage on this application. I authorize the jurisdictions to which this application is made to give any information concerning me, as permitted by law, to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information. I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure. For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state. I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or requested by the jurisdiction(s). __________________________________________________ Month/Day/Year _________________________________________________________________ Original Applicant Signature _________________________________________________________ Full Legal Name (Printed or Typed) Attachments 39 1. 2. The following attachments must accompany the application otherwise the application may be returned unprocessed or considered deficient. For Non-Resident License Applications and unless otherwise noted in the State Matrix of Business Rules, a state will rely on an electronic verification of an ApplicantвЂ™s resident license through the NAICвЂ™s State Producer Licensing Database in lieu of requiring an original Letter of Certification from the resident state. Any jurisdiction specific attachments listed in the State Matrix of Business Rules (www.nipr.com). В© 2011 National Association of Insurance Commissioners Page 5 of 5 CAUTIONВ LAWВ ENFORCEMENTВ CHECKLISTВ В 1.CheckВ forВ PhotoВ IDВ ofВ ApplicantВ 2.ChooseВ вЂњApplicantвЂќВ WorkвЂђFlowВ onВ theВ LiveвЂђscanВ deviceВ 3.FollowВ theВ ElectronicВ FingerprintВ SubmissionВ В В В В В В ReleaseВ ofВ InformationВ formВ forВ theВ В В В ApplicantВ WorkвЂђFlowВ 4.FingerprintsВ areВ automaticallyВ В В submittedВ toВ theВ SBIВ afterВ theВ optionВ toВ printВ aВ fingerprintВ cardВ 5.PleaseВ contactВ theВ ApplicantВ UnitВ atВ 919вЂђ662вЂђ4509В ExtВ 6330,В 6366,В 6397В forВ anyВ additionalВ assistanceВ North Carolina Department of Insurance Fingerprint/Criminal Background Packet Insurance Producer This packet contains instructions on how to submit Fingerprint/ Criminal Background information to Agent Services Division: The information on page 1 is needed to assist in troubleshooting any problems with your fingerprint submission from the local law enforcement agency to SBI. Demographic Information SSN Last Name First Name Residential Street Address Residence Phone Number City State Business Phone Number E-Mail Address (Personal) NIPR Transaction Number Middle Name Zip Code Cell Phone Number E-Mail Address Business Date passed exam at Pearson Vue/surrendered License in previous home state License Type(s) Law Enforcement Agency used for Live Scan Date Signature of Applicant Date Instructions After cancelling a resident insurance license another state/Passing an initial North Carolina Insurance Exam Make application for insurance license at www.nipr.com Complete pages 1-4 of the Fingerprint/Criminal Background Packet Use selected local live scan location o Submit pages 3-4 (Electronic Fingerprint Submission release of information and Applicant information) o Local live scan location will charge a fee for processing forms (fees may vary) Submit completed packet (pages 1-4) to the Agent Services Division by e-mail or fax. If e-mail or fax is not an option mail completed packets. E-mail: Fax Mail asd@ncdoi.gov 919-715-3794 1204 Mail Service Center Raleigh, NC 27699-1204 Page 1 Page 2 AUTHORITY FOR RELEASE OF INFORMATION I authorize the North Carolina Department of Justice through the STATE BUREAU OF INVESTIGATION, Special Operations Division, to perform a fingerprint search of the State's criminal history record file and a fingerprint search of the FEDERAL BUREAU OF INVESTIGATION'S files for a national criminal history record check in connection with my application for licensing with the NC DEPARTMENT OF INSURANCE вЂ“ INSURANCE PRODUCER LICENSE pursuant to NCGS В§ 58-33-48. (Type or Print clearly) Last Name Social Security Number First Middle Maiden Date of Birth Sex Race ____________________ _______ _______ (Optional*) __________________ I understand that the North Carolina State Bureau of Investigation, Special Operations Division, and its officials and employees shall not be held legally accountable in any way for providing this information to the above named agency, and I hereby release said agency and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the agency cannot provide a hard copy of the results of this criminal history record check to me. *Disclosure of social security number is entirely voluntary and not required. If disclosed, the social security number will be utilized to assist with accurate identification/exclusion of possible criminal history records. Applicant's/Employee's Signature _______________________________________ Date ________________________ This form must be maintained on file with the above named agency for one year. Do not mail this form or a copy of this form to the State Bureau of Investigation. Page 3 ELECTRONIC FINGERPRINT SUBMISSION RELEASE OF INFORMATION I authorize the North Carolina Department of Justice through the State Bureau of Investigation, Criminal Information and Identification Section, to perform a national criminal history record check in connection with my application for license with the Department of Insurance вЂ“ Agent Services Division pursuant to NCGS 58-33-48. (Insurance Producer License) I understand that the North Carolina State Bureau of Investigation, Criminal Information and Identification Section, the Federal Bureau of Investigation, and its officials and employees shall not be held legally accountable in any way for providing this information to the above named agency, and I hereby release said agency and persons from any and all liability which may be incurred as a result of furnishing such information. I understand that the above named agency cannot provide a hard copy of the results of this criminal history record check to me. __________________________________ Applicant/LicenseeвЂ™s Signature ___________________________ Date I authorize the above named subject to be fingerprinted and have the fingerprints submitted to the SBI electronically. __________________________________ Etta P. Maynard ___________________________ Date _ Authorized OfficialвЂ™s Printed Name 1204 Mail Services Center, Raleigh, NC 27699 Agency Address _(919) 807-6800 Agency Phone Number I certify that I have taken the fingerprints of the above named subject and forwarded them electronically to the State Bureau of Investigation. ___________________________________ Signature of Official Taking Fingerprints ___________________________ Date Agency Seal/Certification __________________________________________________ _ Page 4 APPLICANT INFORMATION Last Name: ___________________________ Date of Birth: _________________________ First Name: ___________________________ Place of Birth: ________________________ Middle Name: _________________________ Residence: ___________________________ Maiden Name: ________________________ ____________________________________ Aliases: ______________________________ Employer and Address: DOI вЂ“ Agent Services Division 1204 Mail Service Center, Raleigh NC 27699 ____________________________________ Sex: Male _______ Female ________ Race: _______________________________ (write the appropriate letter in the space provided) W вЂ“ White, B вЂ“ Black, I вЂ“ American Indian, A вЂ“ Asian or Pacific Islander, U -Unknown Height: ______________________________ Reason Fingerprinted: Insurance Producer License State and Fed Search В§NCGS 58-33-48 Social Security Number: ________________ (*Optional) Your Case No. (OCA): INSPROD000 Type of Transaction: __NFUF____________ Weight: ______________________________ NC FP Card Type: ______OTH___________ Eye Color: ____________________________ (write the appropriate letters in the space provided) BLK вЂ“ Black BLU вЂ“ Blue HAZ вЂ“ Hazel GRY вЂ“ Gray BRO вЂ“ Brown PNK вЂ“ Pink MAR вЂ“ Maroon GRN вЂ“ Green XXX вЂ“ Unknown Hair Color: _______________________________ (write the appropriate letters in the space provided) BAL вЂ“ Bald BLK вЂ“ Black BLN вЂ“ Blonde or Strawberry BRO вЂ“ Brown GRY вЂ“ Gray or partially RED вЂ“ Red or Auburn SDY -Sandy *Disclosure of social security number is entirely voluntary and not required. If disclosed, the social security number will be utilized to assist with accurate identification/exclusion of possible criminal history records.