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Firm Information

Important Note: All documentation requested in the following questionnaire must be received by Kennedy before final processing of your application and submission to the state(s). This includes such things as license copies as specified, copies of any applicable regulatory sanctions, court or arrest records and all other explanations to any "Yes" answers to the questions. Omitting or withholding of this information is often cause for license suspension, revocation or even criminal prosecution.

General:

3) IF DBA in resident state, do you prefer DBA in nonresident state?
5) Type of Business:

Address:

Legal Data:

23) Duration of Firm:

Stock Information

Entity:

If applicant firm is owned by another entity.

List all officers, directors, stockholders, members and/or partners.

Send additional sheets if necessary.
1)

2)

3)

4)

5)

History and Qualification Information:

83) . Has the firm, or any of it's owners, officers, directors, partners, or members individually or through connection with any other entity ever:
a. Been an officer or employee of a financial institution or a subsidiary of a financial institution?
b. Entered a plea of Nolo Contendere to a criminal action?
c. Been fined by any state or government regulatory agency or authority?
d. Been charged with, arrested for or convicted of a misdemeanor, felony or military offense?
e. Compromised liabilities with creditors, been insolvent or adjudged bankrupt?
f. Been indicted, convicted, enjoined, restrained by a court or regulatory agency for violation of any Federal or State law relating to insurance or securities?
g. Had any professional license (other than insurance) held or applied for revoked, suspended, refused or the renewal thereof denied by a regulatory body of any state, district or territory?
h. Been notified of any delinquent tax obligation that is not subject to a repayment agreement by any jurisdiction to which you are applying?
i. Been found liable in any arbitration proceedings or lawsuit(s) involving allegations of conversion or misappropriation of funds, misrepresentation, breach of fiduciary duty or fraud?

 (If the answer was "Yes" to any of the above questions, a full and complete explanation must be provided on a separate sheet)

84) . Does the firm have branch offices? If yes, send list of addresses and phone numbers for each branch.
85). Has the firm ever had an insurance license denied, suspended, revoked, restricted, canceled, terminated, censured, placed on probation and/or have any regulatory complaints ever been made against it? If yes, send complete explanation
86). Has/is the firm engaged in any other business or activity other than insurance? If yes, give nature of business or activity and time percentage.
87) . Has firm been refused issuance of a Surety or Fidelity Bond, had a bond canceled for cause, or has a surety ever been called upon to pay a claim on the firm's behalf? If yes, send complete details.
88). Has firm ever had an agency contract canceled or an other business relationship with an insurance company terminated for any alleged misconduct or for any reason? If yes, send complete details (dates, companies, reason canceled).
89). Is the firm connected IN ANY WAY with any real estate agency, lending institution or automobile dealer? If yes, state name and address and connection therewith. If lending institution is FDIC insured, please indicate.
90) . Is the firm currently selling insurance over the internet? If yes, identify the following:

Current Resident Licenses (please send copies):

State licenses being applied for:

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