Cal. Code Regs. tit. 10 § 2548.20
State of California
Department of Insurance
Life Producer Notification of Brokering Life Settlements
LIC 441-20N (Rev 04/2014)
_ ___________________________
Producer Licensing Bureau
P.O. Box 1139
Sacramento, CA 95812-1139
(916) 492-3085
Pursuant to Section 10113.2 (b)(1)(D)(ii) of the California Insurance Code
A life insurance producer who is duly licensed as a life agent for at least one year in California or as a licensed nonresident producer in California for one year shall be permitted to operate as a life settlement broker. Not later than 10 days from the first day of operating as a life settlement broker, the life insurance producer shall notify the Commissioner that he or she is acting as a life settlement broker by submitting this form and a fee of $154.
| 1. | ___________________________Name: | |||
| Last | First | Middle | ||
Applicant's Certification:
I certify under penalty of perjury that I have read the foregoing application and know the contents thereof and that each statement therein is full, true and correct. I also certify under penalty of perjury that I have reviewed California Insurance Code, section 10113.1 through 10113.3 and the Commissioner's Life Settlement Regulations, codified in Title 10, Section 2548.1 et seq. of the California Code of Regulations and thoroughly understand the business of life settlements and my obligations as a life settlement broker. I understand that pursuant to sections 10113.1(g)(2)(D) and 10113.2 (b) of the California Insurance Code, any false statement may subject my application to denial and may subject my license/s to suspension or revocation.
APPLICANT'S SIGNATURE: - ______________________________
CITY ______________________________ DATE __________
All fees are filing fees and are not refundable, whether or not the application is acted upon.
| MAIL NOTIFICATION AND FEES TO: | DEPARTMENT OF INSURANCE |
| P.O. BOX 1139 | |
| SACRAMENTO, CA 95812-1139 |
* Disclosure of your U. S. social security number is mandatory pursuant to Cal. Civil Code, § 1798.17; Cal. Family Code, § 17520(d); and Federal Privacy Act of 1974, §§ 7(a) (2) (B) and 7(b). Your social security number will be used primarily for purposes of processing your application, including conducting any necessary investigation into your background. If you fail to disclose your social security number, your application will not be reviewed. An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone (800-967-9331) or by mail, to the following address: 320 Capitol Mall, Sacramento CA 95814.
Cal. Code Regs. Tit. 10, § 2548.20
2. Change without regulatory effect amending NOTE filed 1-24-2012 pursuant to section 100, title 1, California Code of Regulations (Register 2012, No. 4).
3. Renumbering of former section 2548.20 to section 2548.21 and renumbering of former section 2548.19 to new section 2548.20 filed 11-25-2014; operative 1-1-2015 (Register 2014, No. 48).
2. Change without regulatory effect amending Note filed 1-24-2012 pursuant to section 100, title 1, California Code of Regulations (Register 2012, No. 4).
3. Renumbering of former section 2548.20 to section 2548.21 and renumbering of former section 2548.19 to new section 2548.20 filed 11-25-2014; operative 1/1/2015 (Register 2014, No. 48).