REINSURANCE INTERMEDIARY MANAGER
Name:
________________________________________________
1. Name
and address of applicant. (Every licensee must notify this Department,
in writing, of any change in its legal name within 30 days of the change
and include all pertinent legal documentation approving the name change.)
·
Federal Tax ID
number:________________
·
Year
Organized:______________________
·
State of
·
Attach a chart
or listing clearly presenting the identities of and interrelationships among
the applicant and any controlling person of the applicant.
2. Name
and address to be used in license. (Every licensee must notify the
Office, in writing, of any change in residence address or business address within 30
days of the change.
3. Names
and biographical information of each such person to act as
or on the behalf of the reinsurance intermediary.
- This information must be kept current. (Every
licensee must notify this Department in writing within 30 of initiation of
any disciplinary action taken by any jurisdiction against the license or any
other professional licensee or criminal action taken by any jurisdiction
against the licensee.)
4. Affidavit
naming the Arkansas Insurance Commissioner as agent for service of process,
with the same effect as service to the licensee.
- This is a condition precedent to obtaining and/or
maintaining any license issued by the Arkansas Insurance Commissioner.
5. Affidavit
naming a resident of the State of
- This is a condition precedent to obtaining and/or
maintaining any license issued by the Arkansas Insurance Commissioner. No changes shall be effective until
acknowledged by the Commissioner.
6. Affidavit
from an authorized representative of the applicant that all such transactions
performed under the license shall provide the required contract provisions as
stated in Ark. Code Ann. §23-62-408.
7. Affidavit
from an authorized representative of the applicant that the licensee shall be
subject to the regulatory authority of the Arkansas Insurance Commissioner and
the Courts of the State of
8. a. FIVE HUNDRED
DOLLAR ($500) fee for initial application
(nonrefundable).
b. ONE HUNDRED DOLLAR
($100) fee for renewal (annual).
c. SEVENTY-FIVE
DOLLAR ($ 75) fee for designation of Commissioner
as agent for service of process.
9. Annual
Financial Statement.
10. Copy of Certificate of Errors &
Omissions Policy.
11. Name, physical address and email
address of the designated contact person for the application process.
*For
yearly renewal of Reinsurance Intermediary Manager Status, the company should
acknowledge that all licensing information is current and remit the renewal
fee.
Submit
all of the above-required information to the attention of:
Jan Mills, Administrative Specialist
III
Arkansas Insurance Department
1200 West Third Street
Little Rock, AR 72201-1904
501-371-2673, fax 501-371-2747