Del. Admin. Code tit. 18, 2000, 2001, STATE OF DELAWARE-INSURANCE DEPARTMENT, exh. A
INSURANCE DEPARTMENT
STATE OF DELAWARE
1351 WEST NORTH ST., SUITE 101
DOVER, DE 19904
APPLICATION FOR LICENSE AS AN INSURANCE PREMIUM FINANCE COMPANY
TO THE INSURANCE COMMISSIONER OF THE STATE OF DELAWARE:
Application is hereby made for a license to operate an insurance premium finance company.
Company Name: _____________________________________
Address at which applicant will conduct business under license: ___________________
Address of principal place of business within State: _______________________
Address at which all books, records, accounts and documents relating to business in this State will be kept: ________________________________
If applicant is a foreign proprietorship, partnership, or corporation, address of principal place of business: _______________________________
Applicant is
() Individual Proprietor
() Partnership
() Corporation
() Other (Specify)
If applicant is a corporation (Attach Certificate of Incorporation)
State of Incorporation: _______________________
Date of Incorporation: _______________________
If a foreign corporation, name and address of Agent for Service of Process in Delaware: _____________________________________
If applicant has engaged previously in the same or a similar business, provide details, including name(s), address(es), and date(s) first commenced: ___________________________
____________________________________________________________________________
____________________________________________________________________________
State whether applicant is, directly or indirectly, under common ownership, control, or management or is otherwise affiliated or associated with any insurer, or any person, firm or corporation having or exercising control of an insurer.
_ YES _ NO
If "yes," supply complete details: _________________________________________________
____________________________________________________________________
If applicant is a partnership
State whether general partnership or limited partnership: __________________
Give names and addresses of all partners specifically identifying limited partners, if any: _____________________________________________________________________
_____________________________________________________________________
If applicant is a corporation, trust or other entity, other than a partnership, of which ownership is manifested by shares. identify each type of shares and state:
Number of shares authorized: ___________________
Number of shares outstanding ___________________
Par Value: _____________________
Give name, residence address, title and number and per cent of shares directly or beneficially owned by every officer and director and every person, firm or corporation owning or controlling 10% or more of the shares of each type: _______________________________
NAME AND RESIDENCE ADDRESS TITLE NUMBER OF SHARES (%)
________________________________ ______________________________
________________________________ ______________________________
________________________________ ______________________________
Attach current, certified financial statement, which is as of the following dates:
___________________________________________________________________________
In addition to an insurance premium finance company, the following additional business will a conducted at the address of the applicant: ___________________________________
___________________________________________________________________________
If applicant, or any subsidiary, affiliated, or associated insurance premium finance company, has more than one place of business, give the name and address of each:
___________________________________________________________________________
______________________________________________________________________
If the appropriate answer is "Yes" to any of the following questions concerning the applicant, manager, any officer, director, owner or beneficial owner of 10% or more of the shares, complete details must a given including name, address, disposition of charges, etc.
Have any of the above:
Applied previously in this State for a license to engage in the business of insurance premium financing?
_ YES _ NO
Received a rejection, revocation or suspension of license under laws of this State governing insurance premium or other consumer financing?
_ YES _ NO
Received a rejection, revocation or suspension under an insurance premium financing law or regulation, or similar law or regulation in any other State?
_ YES _ NO
Received a revocation or suspension of any license, been convicted or entered a plea of guilty, or nolo contendere, with respect to any law or regulation relating to the business of insurance?
_ YES _ NO
Been arrested, indicted, convicted, entered a plea of guilty or nolo contendere with respect to a State or Federal offense in this or any other State?
_ YES _ NO
Been placed in voluntary or involuntary bankruptcy, receivership, trusteeship, or conservator ship?
_ YES _ NO
Do any of the above now hold a license to engage in the business of insurance premium financing or a similar or related business in any State, District or Territory of the United States?
_ YES _ NO
Form PF-I Delaware
REGULATION NO. 21-INSURANCE PREMIUM FINANCE COMPANIES
Del. Admin. Code tit. 18, 2000, 2001, STATE OF DELAWARE-INSURANCE DEPARTMENT, exh. A