The Arkansas Aid Li Tagy form is an application used by businesses seeking licensure or registration with the Arkansas Insurance Department. This form collects essential information about the business entity, including ownership details, business addresses, and background checks. Completing this form accurately is crucial for compliance with state regulations.
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The Arkansas Aid Li Tagy form is a crucial document for businesses seeking to obtain a title agency license in the state. This form collects essential information about the business entity, including its name, address, and contact details. It requires the identification of all licensed title agents associated with the agency, as well as details about owners, partners, officers, and directors. Additionally, applicants must specify the type of license they are requesting and provide background information on any legal issues that may affect their eligibility. The form emphasizes the importance of complete and truthful responses, as any discrepancies could lead to penalties or revocation of the license. Furthermore, it includes sections for certifications and attestations that reinforce the applicant's commitment to compliance with state insurance laws. Overall, the Aid Li Tagy form serves as a comprehensive application tool for title agencies in Arkansas, ensuring that all necessary information is gathered for the licensing process.
FORM AID-LI-TAGY (9/07)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1200 WEST 3RD STREET
LITTLE ROCK, AR 72201
PHONE: 501-371-2750
FAX: 501-683-2604
TITLE AGENCY
(Please Print or Type)
1
Business Entity Name
2 Incorporation/Formation
3 FEIN
Date
-
4
If assigned, National Producer Number (NP#)
5 If applicable, NASD Firm Central Registration Depository (CRD) Number
6List any other assumed, fictitious, alias or trade names under which you are doing business or intend to do business.
7State of Domicile
8Country of Domicile
9 Is the business entity affiliated with a financial institution/bank?
Yes
No
10Business Address
11City
12State
13Zip Code
14Foreign Country
15
Phone Number
16 Fax Number
17 Business Web Site Address
18 Business E-Mail Address
(
)
19
Mailing Address
20
P.O. Box
21 City
22 State 23 Zip Code
24Foreign Country
Designated/Responsible Licensed Title Agent
25Identify all Licensed Title Agents:
Name
SSN
Owners, Partners, Officers and Directors
26Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity:
Title
SSN/FEIN
Owner: Yes / No
(State Use)
Form AID-LI-TAGY(9/07)
Page 2
Jurisdiction and Type of License/Registration Requested –
27Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.
Legal Business Type:
C – Corporation
P – Partnership
LLC – Limited Liability Company
LLP – Limited Liability Partnership
Background Information
28Please read the following very carefully and answer every question. All copies of documents must be certified. All written statements submitted by the Applicant must include an original signature.
1. Has the business entity or any owner, partner, officer or director ever been convicted of, or is the business entity or any owner, partner,
Yes ___
No___
officer or director currently charged with, committing a crime, whether or not adjudication was withheld?
“Crime”
includes a misdemeanor , felony or a military offense. You may exclude misdemeanor traffic citations and juvenile offenses.
“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
contendre, or having been given probation, a suspended sentence or a fine.
If you answer yes, you must attach to this application:
a)
a written statement explaining the circumstances of each incident,
b)
a
certified copy of the charging document, and
c)
certified copy of the official document which demonstrates the resolution of the charges or any final judgment
2. Has the business entity or any owner, partner, officer or director ever been involved in an administrative proceeding regarding any
professional or occupational license?
“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 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. “Involved” also means having a license application denied or the act of withdrawing an
application to avoid a denial. You may EXCLUDE terminations due solely to noncompliance with continuing education
requirements or failure to pay a renewal fee.
a) a written statement identifying the type of license and explaining the circumstances of each incident,
b) a certified copy of the Notice of Hearing or other document that states the charges and allegations, and
c) a certified copy of the official document which demonstrates the resolution of the charges or any final judgment.
3.
Has any demand been made or judgment rendered against the business entity or any owner, partner, officer or director for overdue
monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding?
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment.
4.
Has the business entity or any owner, partner, officer or director ever been notified by any jurisdiction to which you are applying of any
delinquent tax obligation that is not the subject of a repayment agreement?
If you answer yes, identify the jurisdiction(s): _______________________________________
5. Is the business entity or any owner, partner, officer or director a party to, or ever been found liable in any lawsuit or arbitration proceeding
involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
a written statement summarizing the details of each incident,
a certified copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, and
a certified copy of the official document which demonstrates the resolution of the charges or any final judgment.
6. Has the business entity or any owner, partner, officer or director ever had an insurance agency contract or any other business relationship
with an insurance company terminated for any alleged misconduct?
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)certified copies of all relevant documents.
Page 3
Applicants Certification and Attestation
29The undersigned owner, partner, officer or director of the business entity hereby certifies, under penalty of perjury, that:
1.All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity to civil or criminal penalties.
2.Where required by law, the business entity hereby designates the Commissioner, Director or Superintendent of Insurance, or an appropriate representative in each jurisdiction for which this application is made to be its agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner or Director of that jurisdiction is of the same legal force and validity as personal service upon the business entity.
3.The business entity grants permission to the Commissioner or Director of Insurance in each jurisdiction for which this application is made to verify any information supplied with any federal, state or local government agency, current or former employer or insurance company.
4.Every owner, partner, officer or director of the business entity either a) does not have a current child-support obligation, or b) has a child-support obligation and is currently in compliance with that obligation.
5.I authorize the jurisdictions to give any information they may have concerning me to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information.
6.I acknowledge that I understand and comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.
7.If required, I have received a Certificate of Good Standing from the jurisdiction's Secretary of State in which I am applying.
8.For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state.
Attachments
Must be signed by an officer, director, principal or partner of the business entity:
Month DayYear
____________________________________________
Signature
_________________________________________________
Typed or Printed Name
Social Security Number
Address
City
State
Zip
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