Del. Admin. Code tit. 18, 2000, 2001, STATE OF DELAWARE-INSURANCE DEPARTMENT, exh. B
INSURANCE DEPARTMENT
STATE OF DELAWARE
1351 WEST NORTH ST., SUITE 101
DOVER, DE 19904
APPLICATION FOR RENEWAL LICENSE AS AN INSURANCE PREMIUM FINANCE COMPANY
TO THE INSURANCE COMMISSIONER OF THE STATE OF DELAWARE:
Licensee's Name: ______________________________________________________
Address: _____________________________________________________________
NOTE: The name and address of the licensee as it appears above shall be the same as it presently appears on your license. If any of this information is incorrect, fill in the correct information in the space provided below:
Name: ________________________________________________________
Address: ______________________________________________________
This is a renewal of license number _________, for the year __________
If this is a corporation, give name and address:______________________________
____________________________________________________________________________________
Give names of officers:
President ________________________
Secretary ________________________
Treasurer ________________________
If this is a partnership or proprietorship, give names of partners or proprietor:
____________________________________________________________________
__________________________________________________________________________
Attached is check in the amount of $300 for annual license fee. (Check should be made payable to "Insurance Commissioner, State of Delaware.")
Affidavit
County ______________________
State ________________________
I, _________________________________________ the undersigned, being the ______________________________________________________________________ of the
(Title, if a corporation)
______________________________________________________________________
Name of the insurance premium finance company) swear, (or affirm), that to the best of my knowledge and belief, the statements contained in this application, including the accompanying statements (if any), are true and complete.
By ____________________________________
Title ___________________________________
Subscribed and sworn to before me this ______day of______________, 20_________
____________________________________
Notary Public
Form PF-2
Delaware
Del. Admin. Code tit. 18, 2000, 2001, STATE OF DELAWARE-INSURANCE DEPARTMENT, exh. B