Free lhl206.qxp - Texas


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Date: October 25, 2007
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State: Texas
Category: Workers Compensation
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Texas Department of Insurance
Applications Section: Mail Code 107-1A P.O.Box 12069 Austin, Texas 78711-2069 512-322-3503 www.tdi.state.tx.us

Individual Only
This application form is to be used by individuals not required to pass a qualifying examination through Prometric. It must be typed or printed in ink. Those applicants required to take a qualifying examination must contact Prometric at 866-2670455 or at www.prometric.com/texas for application information and examination reservations. All applicants refer to page 9 for General Information.

Part I ­To be completed by all individual applicants
Applicants must choose only one license type. Those who wish to apply for more than one license type must submit a separate application and fee for each type. Adjusters should read PART II of this application before continuing. License Types (check only one per application):
General Lines­Life, Accident & Health General Lines­Property & Casualty Life Agent Life Insurance Not Exceeding $15,000 Funeral Prearrangement Life Life & Health Insurance Counselor Full-Time Home Office Salaried Employee Personal Lines Property and Casualty Limited Lines County Mutual Insurance Service Representative Managing General Agent Surplus Lines Agent Risk Manager Adjuster­All Lines Adjuster­Property & Casualty Adjuster­Workers' Compensation Adjuster­Trainee Adjuster­Emergency Public Insurance Adjuster Public Insurance Adjuster­Trainee

License Fees: Fees are $50 per license type, or $150 for a temporary license. Make check or money order payable to the Texas Department No fee required for Adjuster-Trainee of Insurance. All license fees are non-refundable and non-transferable. $20 fee required for Adjuster-Emergency

Applicant Information­ Please read carefully and type or print legibly in ink. 1 Applicant's Full Legal Name­nicknames and abbreviations are not acceptable.
LAST NAME FIRST NAME MIDDLE NAME SUFFIX

2 Applicant's Social Security Number, Date of Birth and Daytime Phone Number­The application cannot be processed without this information.
SOCIAL SECURITY NUMBER DATE OF BIRTH (MM-DD-YY) DAYTIME PHONE NUMBER

Disclosure of Social Security Number is required by the Texas Family Code §231.302. 3 Official Mailing Address (required)­This is the address of record with TDI.
STREET, PHYSICAL LOCATION, ROUTE OR P O BOX APARTMENT, SUITE, ETC.

CITY

STATE

ZIP CODE

4 Business Address (required)­This must be the physical business address at which business records of insurance transactions are maintained.
NUMBER & STREET (MUST BE PHYSICAL LOCATION ­ P.O. BOX NOT ALLOWED) APARTMENT, SUITE, ETC.

CITY

STATE

ZIP CODE

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Applications will not be processed until proper documentation or details are received and a review is completed. 5 Excluding traffic violations and first offense DWI: a Do you currently have any pending misdemeanor or felony charges (by indictment, information, or any other instrument) filed against you in Texas, in any other state or by the federal government? No Yes b Have you ever been convicted of any misdemeanor or felony offense in Texas, in any other state or by the federal government? No Yes c Have you ever had adjudication deferred on any misdemeanor or felony charge or offense in Texas, in any other state or by the federal government? No Yes d Have you ever served any period of probation for any misdemeanor or felony offense in Texas, in any other state or by the federal government? No Yes If you answered "Yes" to any of questions 5a­d, you must submit original certified copies of the charging document, indictment, information, or any other charging document, judgment of conviction, and/or deferred adjudication order, probation order, order terminating probation, community supervision and/or parole certificate for each and every crime or offense. If the court states they no longer have the records, please have the court provide us with a letter on their letterhead stating that fact. If you were arrested only and not prosecuted, please provide a records search from the appropriate jurisdiction indicating a final disposition. You must submit a statement describing the circumstances leading to the offense(s). You must include your age at the time(s) of the offense(s).You may provide letters of recommendations from any persons in contact with you that are aware of your criminal past. 6 Have you or has any corporation, partnership, association or firm in which you were a director, officer, shareholder, manager, member or partner, ever been the subject of an administrative or legal action filed by Texas or any other insurance department, or financial regulatory agency, or of an action filed on behalf of Texas or any other state or by the federal government based on alleged violations of state or federal insurance, securities or financial regulatory laws that you have not previously reported to the Texas Department of Insurance? No Yes If you answer "Yes, a license will not be issued until full details of the administrative or legal action are provided. " 7 Are you indebted to any policyholder, insurance or reinsurance company, insurance agency, general agent, managing general agency, premium finance company or court appointed liquidator for premiums collected or commissions retained, or have any claims or judgements been filed against you for retaining premiums or commissions? No Yes If you answer "Yes, a license will not be issued until full details of the indebtedness are provided. " 8 Have you ever had an agency contract or company appointment cancelled for cause (e.g., misrepresentation, misappropriation, etc.)? No Yes If you answer "Yes, a license will not be issued until full details are provided. Cancellation for cause does not include cancella" tions due to license expiration (nonrenewal). 9 During the last 6 months, have you applied for or received a temporary license of the type for which you are now applying? No Yes If you answer "Yes, a temporary license will not be issued. A temporary license may not be renewed or issued more than once in a " consecutive six-month period to the same applicant. Public Insurance Adjuster Trainee applicants see Part III, number 2. 10Do you currently hold any adjuster, public insurance adjuster or insurance agent license in any state other than Texas or have you held any adjuster, public insurance adjuster or insurance agent license in any state other than Texas within the last five years? No Yes If you answer "Yes, you must provide one of the following: " Applicants who have held a resident license in another state within the previous five years from the date of this application must attach a Clearance Letter from the Insurance Commission in the state(s) in which the applicant was previously licensed. A Producer Database printout showing the termination of the license in the applicant's previous resident state(s) can take the place of a Clearance Letter. Applicants holding a current resident license in another state must attach an original Certificate of Good Standing from the Insurance Commission in the applicant's state of residence. The Certificate of Good Standing must be dated within 90 days of receipt of the completed application. A Producer Database print out showing that a current license is held in the applicant's resident state can take the place of a Letter of Certification.
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Part II ­ All Lines Adjusters, Property & Casualty Adjusters, and Workers' Compensation Adjusters Only
Public Insurance Adjusters use Part III Adjusters may add additional qualifications without completing a new application by submitting to TDI a copy of the existing adjuster license along with a copy of the approved course certificate, or by passing the Prometric examination. The Certificate of Completion must show that within the past 12 months the adjuster has completed a certified adjuster prelicensing education program and passed an examination. Adjuster applicants must complete this part with the name of the firm or insurer with whom they will be employed or, if self employed, with the applicant's name. 1 Provide the name of the firm or insurer for whom you will be employed as an adjuster. If self-employed, enter your name.
NAME OF FIRM OR INSURER (OR APPLICANT NAME, IF SELF-EMPLOYED)

2 Adjuster Trainee Registration­An Adjuster Trainee is required to undergo education and training as an adjuster under the direction and supervision of a licensed sponsoring adjuster. Authorization to act as an Adjuster Trainee may not exceed 12 months. The Adjuster Trainee registration may not be renewed. An Adjuster Trainee must be sponsored by a licensed adjuster. The sponsoring licensed adjuster must complete the following certification. This is to certify that the above-mentioned applicant will undergo education and training as an adjuster under my direction and supervision as required in Texas Insurance Code, § 4101.003.

SIGNATURE OF SPONSORING LICENSED ADJUSTER

DATE SIGNED

PRINT LEGAL NAME OF SPONSORING LICENSED ADJUSTER

TDI LICENSE NUMBER OF SPONSORING ADJUSTER

3 Emergency Adjuster­An Emergency Adjuster License may be issued to an individual to adjust losses as a result of a catastrophe or emergency. The sponsoring licensed adjuster or insurance company must provide details of the catastrophe requiring the issuance of an Emergency Adjuster License. The details must include the date, location, kind of catastrophe, and a copy of official notice of the catastrophe or emergency. TDI catastrophe bulletins are posted at www.tdi.state.tx.us/commish/bulletins/cat96.html. An Emergency Adjuster must be sponsored by either a licensed adjuster or a licensed and approved insurance company. The mailing address of the Emergency Adjuster sponsor must be provided. Emergency Adjuster Licenses are issued for 90 days. Emergency Adjuster applicants are not required to provide fingerprints. Provide location and details of the catastrophe that the above-named applicant intends to work.

4 This is to certify that the above-named applicant will be working catastrophe claims at the above location(s) resulting from the catastrophe named in the attached official notice. I will be responsible for the loss or claims practices of the Emergency Adjuster License holder as required in Texas Insurance Code, § 4101.101.

SIGNATURE OF SPONSORING LICENSED ADJUSTER OR SPONSORING COMPANY OFFICIAL

DATE SIGNED

Print legal name of sponsoring licensed adjuster or company official and sponsoring company
NAME TDI LICENSE NUMBER OF SPONSORING ADJUSTER SPONSORING COMPANY NAIC NUMBER

MAILING ADDRESS OF SPONSORING ADJUSTER OR SPONSORING INSURANCE COMPANY

CITY

STATE

ZIP CODE

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Part III­Public Insurance Adjusters Only
Public Insurance Adjuster license applicants and trainee registration applicants must complete this part of this application. 1 Provide the name of the firm or person for whom you will be employed as a public insurance adjuster, or if self-employed, enter your name.
NAME OF EMPLOYER (OR APPLICANT NAME, IF SELF-EMPLOYED)

2 Public Insurance Adjuster Trainee Registration­A public insurance adjuster trainee is required to register and undergo education and training as a public insurance adjuster under the direction and supervision of a licensed sponsoring public insurance adjuster. Authorization to act as a public insurance adjuster trainee may not exceed 180 days, but may be renewed, so long as the registrant does not hold any more than two certificates, including renewals, within an 18 month period. A trainee certificate may be renewed by filing another fully completed application with the required $50 fee with the department not more than 30 days prior to the expiration of an existing trainee certificate. The sponsoring licensed public insurance adjuster must complete the following certification. I certify that the above-mentioned public insurance adjuster trainee registration applicant will undergo education and training as an adjuster under my direction and supervision as required in Texas Insurance Code, § 4102.069 and that I continue to meet the public insurance adjuster financial responsibility requirement.
SIGNATURE OF SPONSORING LICENSED PUBLIC INSURANCE ADJUSTER DATE SIGNED

PRINT LEGAL NAME OF SPONSORING LICENSED PUBLIC INSURANCE ADJUSTER

TDI LICENSE NUMBER OF SPONSORING PUBLIC INSURANCE ADJUSTER

3 Financial Responsibility­Each public insurance adjuster license applicant and trainee registration applicant must demonstrate proof of financial responsibility with a surety bond executed with the applicant as sole principal in the amount of not less than $10,000 payable to the Texas Department of Insurance on a bond form available from TDI or at the agent section of www.tdi.state.tx.us. See Texas Insurance Code, § 4102.105 and 28 Texas Administrative Code §§19.705­19.707. The original bond must be attached to this application. I have attached my original Public Insurance Adjuster Bond. No Yes 4 Fingerprints­Each resident public insurance adjuster license applicant and trainee registration applicant must file with this application a copy of receipt from L1 Identity Solutions (formerly IBT or Identix Identification Services) or Prometric evidencing that your fingerprints have been electronically submitted to the Texas Department of Public Safety. Nonresident applicants must submit fingerprint receipt or a complete set of fingerprints on the original fingerprint card as allowed under Exception to Electronic Fingerprinting in Commissioner's Bulletin #B-0045-06. This bulletin may be viewed at www.tdi.state.tx.us. The copy of your fingerprint receipt or original fingerprints are required, unless previously submitted to TDI with another license application and the applicant holds an active TDI license. I have an active TDI license and I have already submitted fingerprints to TDI with another license application or I have attached a copy of my fingerprint receipt or I was not able to electronically submit my fingerprints to DPS. I have attached my original fingerprint card with a $34.25 check or money order made payable to DPS. Fingerprints provided for this application shall be used to check criminal history records of the Texas Department of Public Safety and the Federal Bureau of Investigation in accordance with applicable statutes. 5 Criminal History Record­Each nonresident public insurance adjuster license applicant and nonresident trainee registration applicant must file with this application an original criminal history record of the applicant obtained from the state law enforcement agency of the applicant's state of residence. I have attached my original criminal history records. No, I am a resident of Texas Yes, the record is attached. 6 Agent for Service of Process­All nonresident applicants for a public insurance adjuster license must provide the name and address of their agent for service of process in the State of Texas as required in Texas Insurance Code, § 4102.107.
NAME OF TEXAS AGENT FOR SERVICE OF PROCESS

TEXAS ADDRESS OF AGENT FOR SERVICE OF PROCESS

CITY

STATE

ZIP CODE

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Part IV­ Surplus Lines Agents Only
1 Provide your current General Lines-Property and Casualty Agent or Managing General Agent TDI license number. (You must hold a current General Lines-Property and Casualty license or a Managing General Agent license to qualify for a Surplus Lines license.)
LICENSE NUMBER

Part V­ Insurance Service Representatives Only
Certificate for Insurance Service Representatives­Must be completed by the appointing licensed General Lines­Property and Casualty Agent or Personal Lines Property and Casualty Agent or an officer or partner of a licensed General Lines­Property and Casualty Agency or Personal Lines Property and Casualty Agency.

CERTIFICATE FOR INSURANCE SERVICE REPRESENTATIVES
This is to certify that the above-mentioned applicant is appointed to act as an Insurance Service Representative (ISR) for this General Lines­Property and Casualty Agent/Agency or Personal Lines Property and Casualty Agent/Agency in the State of Texas, subject to the applicant's qualifying for a license. If and when this appointment is terminated or canceled, the Department must be notified immediately of such termination. The ISR Transfer/Cancel Employment Form LHL208 may be found at the agent page of www.tdi.state.tx.us. Appointing General Lines­Property and Casualty or Personal Lines Property and Casualty AGENT:

SIGNATURE OF SPONSORING AGENT

PRINT OR TYPE SPONSORING AGENT'S LEGAL NAME

AGENT'S TDI LICENSE NUMBER

(As it appears on the current license)

Appointing General Lines­Property and Casualty or Personal Lines Property and Casualty AGENCY:

SIGNATURE OF AGENCY OFFICER OR PARTNER

PRINT OR TYPE SIGNING OFFICER'S OR PARTNER'S NAME

PRINT OR TYPE SPONSORING AGENCY'S NAME

AGENCY'S TDI LICENSE NUMBER

(As it appears on the current license)

DATE SIGNED

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Part VI­Notice of Appointment (General Lines Agents [GL], Life Agents [LAGT], Limited Lines Agents [LL],Funeral Prearrangement Life Agents[PN], Life Insurance Not Exceeding $15,000 Agents[LI], County Mutual Agents [CM], Managing General Agents[MGA], Personal Lines Property and Casualty Agents[PLPC] and Full-Time Home Office Salaried Employees [HOSE] Only) Notice of Appointment. To make a company or subagent appointment with the license application, the Notice of Appointment form on Page 7 of 10 must be signed in ink by an authorized appointing official of the appointing INSURANCE COMPANY, AN EXECUTIVE OFFICER OR PARTNER OF THE SPONSORING AGENCY, OR THE SPONSORING INDIVIDUAL AGENT. The form will be rejected if it does not contain the title and original signature of the signing representative. The applicant's signature will not be accepted. The Notice of Appointment must include the date the form is signed. A Notice of Appointment does not apply to Insurance Adjuster, Public Insurance Adjuster, Risk Manager, Surplus Lines, Insurance Service Representative, or Life and Health Insurance Counselor Licenses. Temporary License. Only applicants for a Funeral Prearrangement Life Agent, Life Insurance Not Exceeding $15,000 Agent, or County Mutual Agent License may apply for a temporary license with this application. If a temporary license is requested by the appointing company and if the company and applicant are eligible, TDI will issue such a license for a period of 90 days, without examination. A temporary license may not be renewed or issued more than once in a consecutive six-month period to the same applicant. A temporary license application must include a completed Notice of Appointment. The temporary licensee must provide to TDI a certification by the appointing insurance company that the temporary agent has completed the required course of study and passed the written examination with a copy of the temporary license within one year of the temporary license's issue date in order to obtain the permanent license without a new application. A Registration of Full-Time Home Office Salaried Employee application must include a completed Notice of Appointment. Insurance Company Appointments. If a completed Notice of Appointment is not received with a General Lines Agent, Life Agent, Limited Lines Agent, Funeral Prearrangement Life Agent, Life Insurance Not Exceeding $15,000 Agent, County Mutual Agent, Managing General Agent or Personal Lines Property and Casualty Agent License application, the license may be issued. However, not later than the 30th day after the effective date of the agent's appointment by the insurance company, a TDI Notice of Appointment with the $10.00 fee must be submitted to TDI. Subagent Appointments. ONLY GENERAL LINES AGENTS, PERSONAL LINES PROPERTY AND CASUALTY AGENTS AND LIFE AGENTS MAY APPOINT SUBAGENTS OR BE APPOINTED AS SUBAGENTS. · A General Lines ­ Life, Accident and Health Agent may appoint a General Lines ­ Life Accident and Health Agent or a Life Agent. · A Life Agent may appoint a General Lines ­ Life Accident and Health Agent or a Life Agent. · A General Lines ­ Property and Casualty Agent may appoint a General Lines ­ Property and Casualty Agent or a Personal Lines Property and Casualty Agent. · A Personal Lines Property and Casualty Agent may appoint a General Lines ­ Property and Casualty Agent or a Personal Lines Property and Casualty Agent. Applicants for a Limited Lines, Funeral Prearrangement Life, Life Insurance Not Exceeding $15,000, County Mutual, Managing General Agent License, or a Full-Time Home Office Salaried Employee Registration cannot be appointed by an agency or agent. NOTICE OF APPOINTMENT FOLLOWS ON THE NEXT PAGE.

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PLEASE FOLLOW INSTRUCTIONS ON PREVIOUS PAGE.

NOTICE OF APPOINTMENT FOR GL, LAGT, LL, PN, LI, CM, MGA, PLPC AND HOSE APPLICANTS

APPLICANT'S FULL LEGAL NAME (AS SHOWN IN PART I OF THIS APPLICATION)

Only ONE sponsor per application. Enter company, agency of agent information. Name of Company appointing a GL, LAGT, LL, PN, LI, CM, MGA, PLPC or HOSE applicant:
APPOINTING COMPANY NAME (GROUP NAMES NOT ACCEPTABLE) NAIC NUMBER OF APPOINTING COMPANY

OR--Name of Agency sponsoring a GL, LAGT or PLPC as a Subagent:
SPONSORING AGENCY NAME AGENCY TAX ID NUMBER

(AS IT APPEARS ON THE CURRENT AGENCY LICENSE)

OR--Name of Agent sponsoring a GL, LAGT or PLPC as a Subagent:
SPONSORING AGENT NAME SSN OF SPONSORING INDIVIDUAL AGENT

(AS IT APPEARS ON THE CURRENT AGENT LICENSE)

Temporary License: (for PN, LI, or CM license types only): Does this company want the above named applicant to receive a temporary license to act as a full-time agent in accordance with the provisions of the Texas Insurance Code? NO YES If "Yes", please provide the telephone number of the office where the agent will be assigned: (______) __________________ Managing General Agent: This section must be completed by an officer of the appointing company or carrier having personal knowledge that the applicant has had experience or instruction that would qualify the applicant as a managing general agent. · Will the above managing general agent applicant have claim settlement authority for the company or carrier? · Does the claim settlement authority exceed $25,000 on any one claim? · Does the claim settlement authority include third-party liability other than property damage? · Are funds exceeding $100,000 customarily held by the managing general agent for the purpose of paying losses and loss adjustment expenses for the company or carrier?

Yes Yes

No No

Yes

No

Yes

No

The Appointing Official must read and sign the following statements: This is to certify that the above-mentioned applicant is appointed to act as an agent for this company OR a subagent for my agency OR a subagent for me in the State of Texas subject to the applicant's qualifying for a license. If and when this appointment is terminated or canceled, the Department will be notified immediately of such termination. This applicant meets the requirements as set out in the Texas Insurance Code and the rules and regulations promulgated by the Texas Department of Insurance for the type of license applied for herein. I acknowledge my responsibility for ensuring that the applicant receives training if required by the Texas Insurance Code.

SIGNATURE OF APPOINTING OFFICIAL OF APPOINTING INSURANCE COMPANY OR EXECUTIVE OFFICER OR PARTNER OF APPOINTING AGENCY OR APPOINTING INDIVIDUAL AGENT

PRINT OR TYPE APPOINTING OFFICIAL'S LEGAL NAME AND TITLE OR OFFICER'S OR PARTNER'S LEGAL NAME AND TITLE OR INDIVIDUAL AGENT'S LEGAL NAME

DATE SIGNED

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Part VII­Background Information and Fingerprints
This part must be completed by all applicants except public insurance adjuster and public insurance adjuster trainee registrants. Public insurance adjuster license applicants and trainee registration applicants must complete Part III and skip this part. 1 I am a resident of Texas: a Yes, I have attached a copy of my fingerprint receipt from L-1 Identity Solutions (formerly IBT or Identix) or Prometric evidencing that my fingerprints have been electronically submitted to the Texas Department of Public Safety or b Yes, I have an active TDI license and I have already submitted fingerprints to TDI with another license application or c Yes, and I was not able to electronically submit my fingerprints to DPS and I have attached my original fingerprint card with a $34.25 check or money order made payable to DPS or d I am not a resident of Texas (answer question number 2) Resident applicants must include a copy of their fingerprint receipt or card unless the applicant (1) has an active TDI license and (2) submitted fingerprints to TDI with another license application. Fingerprints will be used to check criminal history records of the Texas Department of Public Safety and the Federal Bureau of Investigation in accordance with applicable statutes. 2 I am a nonresident of Texas and I meet the background information requirement as follows: a I hold a current license in good standing in my home state as reflected on the National Association of Insurance Commissioner's Producer Database or b I have attached my criminal history records that I have acquired from my resident state's law enforcement agency or c I have attached a current Certificate of Good Standing from my resident state. All nonresident license applicants who do not hold a current insurance license in good standing in the applicant's state of residence shall, through the law enforcement agency of the state of residence, submit a copy of the applicant's criminal history records. If the resident state will not provide a criminal history record for licensing purposes, the applicant must provide a receipt of electronic fingerprints or a fingerprint card with a $34.25 check or money order payable to DPS.

Part VIII­Individual Applicant Signature Page (to be completed by all applicants)
All Applicants must read, sign, and have this section notarized before submitting the license application. I hereby certify that I have personally answered each of the questions herein and that the answers are true and correct to the best of my knowledge and belief. I further certify that I am aware of the provisions of the Texas Insurance Code and the rules and regulations promulgated by the Texas Department of Insurance which relate to the issuance of the license for which I am applying and the grounds under which such license may be denied, suspended, revoked or non-renewed, and that I meet the requirements for the license type applied for herein. I further acknowledge that I am subject to both disciplinary action and criminal prosecution if my application contains a false, fictitious, or fraudulent statement or entry with regard to any material fact. I understand that fingerprints provided with this application shall be used to check criminal history records of the Texas Department of Public Safety and the Federal Bureau of Investigation in accordance with applicable statutes. I acknowledge and understand that I have the duty to inform the Commissioner of Insurance of any disciplinary action taken against me in any other state in which I may be licensed within thirty (30) days of the happening of such disciplinary action. I further acknowledge that I have the duty to update the information contained on this application, including a change of my address, and that failure to do so may constitute grounds for revocation or suspension of my insurance license(s).
SIGNATURE OF APPLICANT

FULL LEGAL NAME OF APPLICANT (PRINT OR TYPE)

The State of Before me,
(PRINTED NAME OF NOTARY PUBLIC) (PRINTED FULL LEGAL NAME OF APPLICANT)

, County of__________________________________________ , , on this day personally appeared , known to me (or proved to me or through
(DESCRIPTION OF IDENTITY CARD OR OTHER DOCUMENT)

on the oath of

(PRINTED NAME OF WITNESS KNOWN TO NOTARY PUBLIC)

)

to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that (s)he executed the same for the purposes and consideration therein expressed. Given under my hand and seal of office this
(NOTARY SEAL)

day of
(NOTARY PUBLIC SIGNATURE)

, A.D.

Notary Public, State of Send completed application, check or money order, made payable to the Texas Department of Insurance, and other required documents to: Texas Department of Insurance Applications Section MC 107-1A P.O.Box 12069 Austin, Texas 78711-2069
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General Information
LICENSE TYPE PART I PART II PART III PART IV PART V PART VI PART VII PART VIII

General Lines­LAH (§ 4054.051) General Lines­P&C (§ 4051.051) Personal Lines Property and Casualty (Chapter 4051) Limited Lines (§ 4054.101 and § 4051.101) *Life Insurance Not Exceeding $15,000 (§ 4054.201) *Funeral Prearrangement Life (§ 4054.151) L&H Insurance Counselor (Chapter 4052) Life Agent (Chapter 4054) *County Mutual (§ 4051.201) Insurance Service Representative (§ 4051.151) Managing General Agent (Chapter 4053) Surplus Lines Agent (Chapter 981) Risk Manager (Chapter 4153) Full-Time Home Office Salaried Employee (§ 4051.301) Adjuster­All Lines (Chapter 4101) Adjuster­P&C (Chapter 4101) Adjuster­Workers' Comp (Chapter 4101) Adjuster­Trainee (§ 4101.003) Adjuster­Emergency (§ 4101.101) Public Insurance Adjuster (Chapter 4102) Public Insurance Adjuster­Trainee (Chapter 4102)

· · · · · · · · · · · · · · · · · · · · ·

· · · · · · · · · ·

· · · · · · · · · · · · · · · · · · ·

· · · · · · · · · · · · · · · · · · · · ·

· Required parts * A temporary license is available for this license type. A Part VI, Notice of Appointment is required for a temporary license, otherwise the Notice of Appointment is optional on this original application. Notice of Appointment is optional for these types on an original application. However, not later than the 30th day after the effective date of the agent's appointment by an insurance company, or subagent's appointment by a General Lines agent /agency, a Notice of Appointment with the $10 fee must be submitted to TDI, if the Notice of Appointment is not made on this application. If Notice of Appointment is not submitted, then company certification must be provided certifying the applicant has (1) completed a course of study and instructions and (2) passed without aid a written examination administered by the insurer as required in the Texas Insurance Code. License type information and descriptions, including examination requirements and exemptions, may be found at

www.tdi.state.tx.us/agent/aglityp.html
This application with fee and required attachments must be mailed to: Texas Department of Insurance, MC 107-1A P O Box 12069 Austin TX 78711-2069 Notice About Certain Information Laws and Practices With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you. Under Sections 552.022 and 552.023 of the Texas Government Code, you have the right to review or receive copies of information about yourself, including private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under Section 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please contact the Agency Counsel Section of TDI's Legal Services at (512) 475-1757 or visit the Corrections Procedure section of TDI's Web site at www.tdi.state.tx.us 28 Texas Administrative Code §§ 19-801­19.803: All $50 application and $150 temporary license application fees are nonrefundable and nontransferable as authorized by the Texas Insurance Code. Make check or money order payable to the Texas Department of Insurance. Applicants with Expired Licenses: If a person's license has been expired for more than 90 days but less than one year, the person may not renew the license, but is entitled to a new license without taking the applicable examination if the person submits to TDI a new application, the license fee, and an additional fee equal to one-half of the license fee. If a person's license has been expired for one year or more, the person may obtain a new license by submitting to reexamination, if examination is required for original issuance of the license, and complying with the requirements and procedures for obtaining an original license.
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General Information (continued)
Temporary License Applicants: Only applicants applying for a Funeral Prearrangement Life License, Life Insurance Not Exceeding $15,000 License or County Mutual License may apply for a temporary license with this application. All other temporary license applicants must submit a Prometric application form to Oak Hill Technology, Inc., 4544 South Lamar, Suite 710, Austin, TX 78745. The temporary license application must include a completed Notice of Appointment, Part VI, signed by the appointing company. The temporary license is valid for 90 days after the date of issuance. A temporary license holder must submit to the Department a certification by the appointing insurance company that the temporary agent has completed the course of study and examination as required by the Texas Insurance Code with a copy of the temporary license to obtain a permanent Funeral Prearrangement Life License, Life Insurance Not Exceeding $15,000 License or the County Mutual License. A temporary license may not be renewed or issued more than once in a consecutive six-month period to the same applicant. Public Insurance Adjuster Trainee Registrations­A public insurance adjuster trainee registration expires after 180 days. A public insurance adjuster trainee who wishes to obtain a public insurance adjuster license must pass the Prometric examination and complete the Prometric application and submit it to Oak Hill Technology, Inc. with the required $50.00 fee. You may obtain information on the Prometric examination and the Prometric application at

www.prometric.com/texas
Names: Applicants must supply their full, legal name and not a nickname. For instance, a Christopher may not apply as Chris. Addresses: The official mailing address provided in Part I, number 3 must be your permanent mailing address and is the address of record to which official correspondence, forms, notices and other information will be sent. Address changes must be reported to TDI as required in the Texas Insurance Code, § 4001.252 and § 4003.009. If this official mailing address changes, the applicant/agent must notify TDI, in writing, either by fax to

512-322-3553
or by mail to Texas Department of Insurance Licensing Mail Code 107-1A P O Box 149104 Austin TX 78711-9104 You may obtain the Licensee Address Change Request Form at

www.tdi.state.tx.us/forms/agents.html
All address change requests must be dated and signed by the license holder. Fingerprinting: Effective January 1, 2007, anyone who must provide fingerprints to the Texas Department of Insurance (TDI) must pay an additional $34.25 fingerprint processing fee. The new fee is required under Commissioner's Order number 06-1077 that adopts amended 28 TAC §1.501 and new §§1.503 ­ 1.509. The complete text of the rule may be accessed at: http://www.tdi.state.tx.us/rules/2006/1003-059.html. The $34.25 processing fee will pay for criminal history background checks by both the Texas Department of Public Safety (DPS) and the Federal Bureau of Investigation (FBI). The $34.25 is in addition to the $9.95 fingerprint collection fee charged by the companies that take electronic fingerprints for the State of Texas and any other license or application fees. In addition to the new fee, the process of having fingerprints taken and attaching the fingerprint cards to the application has changed to implement electronic fingerprinting through approved vendors as authorized under the rule. Electronic fingerprinting is fast and accurate, and in most cases will avoid potential delays in the processing of your submission. The general process effective January 1, 2007, is: 1 Print and complete the FAST Pass form from TDI's website, http://www.tdi.state.tx.us/forms/agents.html. You will need information from the FAST Pass when you make your fingerprint appointment. 2 Schedule an appointment to be fingerprinted. Pursuant to DPS requirements on the vendor, you will be photographed as part of the fingerprint process. You must pay the $34.25 fee plus a $9.95 fingerprint collection fee ($44.20 total) to the vendor in a manner that is acceptable to that vendor. All fingerprint appointments will be made by DPS' vendor, L-1 Identity Solutions (formerly IBT or Identix Identification Services). The vendor has 60+ Texas fingerprint locations, including the Prometric testing centers which administer the TDI agent/adjuster licensing examinations. Schedule at http://www.ibtfingerprint.com or call toll-free 1-888-467-2080 (8 a.m 5 p.m. CST). 3 Arrive at your scheduled appointment with your FAST Pass. After your fingerprints and photograph are taken, the technician will give you a receipt stating that you were fingerprinted. Do not throw away the receipt. You will not get a printed fingerprint card. Your fingerprints will be sent electronically to DPS and the FBI.
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4 Attach a copy of your fingerprint receipt to your application. You will be sending the receipt copy instead of sending a paper fingerprint card. Keep the original receipt for your records. Exception to Electronic Fingerprinting Non-resident public insurance adjuster applicants may continue to submit paper fingerprint cards even after January 1, 2007, because electronic fingerprinting for TDI may be available only at sites located in Texas. Non-residents, however, may contact L-1 Identity Solutions (formerly IBT or Identix Identification Services) to determine if it has local fingerprinting facilities that can process fingerprints for TDI electronically. Also, resident applicants may submit a paper fingerprint card; however, paper fingerprints may substantially delay the processing of these applications both due to longer processing times and because it will increase the likelihood that the fingerprint will be rejected by DPS or FBI and require a reprint. Additionally, beginning January 1, 2007, all fingerprints captured on paper cards must be captured by a criminal law enforcement agency. Persons submitting paper cards should mail the application to the address given on the application along with the paper fingerprint card and a $34.25 check or money order payable to DPS. The $34.25 fee applies to all applications submitted to TDI on or after January 1, 2007. TDI will forward the fee payment and the fingerprint card to DPS. NOTICE: Applications received after January 1, 2007, with an original fingerprint card without the required $34.25 check or money order payable to DPS will be returned to the applicant unprocessed. You may view the Texas Insurance Code at

www.legis.state.tx.us
or the Texas Administrative Code at

http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=3&ti=28&pt=1 Please visit www.tdi.state.tx.us for additional information.

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