Alight Licensing and Contracting Data Form

Alight Licensing and Contracting Data Form

Personal Information

Legal Last Name*

Legal First Name*

Middle Name (if applicable)

Have you ever used another name? (Alias/ Maiden)*

Select

Prior name(s) used.

Date of Birth*

Place of Birth State*

Select or enter value

Place of Birth City*

Place of birth Country*

Gender*

Select or enter value

Are you a citizen of the United States?*

Select

If not a citizen of the United States, indicate country:

Contact Information

Home Address*

Home Address 2 (apt #)

City/Town*

State (2 letter abbreviation)*

Select or enter value

Zip code*

County of Resident in your Home State*

Personal Email Address*

Personal Phone Number*

Phone

Drivers License/State Identification Information

Name on Driver's License/State ID*

State of Issue*

Select or enter value

Driver's License/State ID Number*

Driver's License- Date Issued*

Resident License Information

Name on Resident License*

Resident State*

Select or enter value

NPN Number*

License Number*

Is your license active?*

Select or enter value

Expiration Date: For FL, ME, MI - use your CE credit expiration date

Background Check Information

Question 1a: Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a misdemeanor?

You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence (DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.

You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)

Question 1a:*

Select or enter value

Question 1b. Have you ever been convicted of a felony, had judgment withheld or deferred, or are you currently charged with committing a felony?

You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)

If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of insurance in your home state as required by 18 USC 1033?

If so, was consent granted? (Attach copy of 1033 consent approved by home state.)

Question 1b*

Select or enter value

Question 1c Have you ever been convicted of a military offense, had a judgment withheld or deferred, or are you currently charged with committing a military offense?

Question 1c*

Select

NOTE: For Questions 1a, 1b and 1c, “Convicted” 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 to any of these questions, 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.

Question 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?

"Involved” 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. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. “Involved” 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.

Question 2*

Select

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.

Question 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.

Question 3*

Select

If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and location of bankruptcy.

Only PDF, PNG, JPG, JPEG, GIF files are ...accepted

Question 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?

Question 4*

Select

If you answered YES, identify the jurisdiction(s)

Question 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

Question 5*

Select

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.

Question 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?

Question 6*

Select

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.

Question 7: Do you have a child support obligation in arrearage?

Question 7 *

Select

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.)

If yes to Question 7a

If yes to Question 7b

Select

If yes to Question 7c

Select

Thank you for completing the Licensing form.

If anything, additional is needed our team will reach out with questions.

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