SURPLUS LINES BROKER LICENSE APPLICATION by owc12988

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									Licensing Division                                      Ohio Department of Insurance
50 W. Town St., 3rd Fl.
                                                                  Ted Strickland – Governor
Suite 300
                                                                  Mary Jo Hudson – Director
Columbus, OH 43215
(614) 644-2665
Fax # (614) 387-0087                          SURPLUS LINES BROKER LICENSE
www.insurance.ohio.gov
                                                      APPLICATION

1 Soc. Security Number/FEIN


2 Agent Last Name, First Name, Middle Initial/Business Entity Name                                                     3 Date of Birth/Incorporation Date


4 Residence/Home Address (Physical Street)                        5 P.O. Box          6 City                           7 State      8 Zip


9 Home Phone Number                    10 Are you a Citizen of the United States? (Check One)

(             )                                   Yes         No (If No, of which country are you a citizen?)
11 Business Address (Physical Street)                            12 P.O. Box         13 City                          14 State      15 Zip



                                                               Background Information
16 The Applicant must read the following very carefully and answer every question:

    1.     How long have you been a property and casualty agent/business entity?

    2.     Do you agree that if your license is issued you will conform to the requirements of Section 3905.30 to 3905.37 of the      Yes     No
           Ohio Revised Code?

    3.     Do you understand that a surplus lines broker violates the law if he/she accepts brokerage business from persons other     Yes     No
           than a property and casualty agent duly licensed by the Ohio Department of Insurance.

                                                                   Applicant Signature
17 The Applicant must read the following very carefully:


I do solemnly swear or affirm that I am the person named herein and that I have completed this application myself and that the statements contained
herein are true.




         Original Applicant/Business Entity Representative Signature                   Date



         Full Legal Name (Printed or Typed)


                                                                       Attachments
18 Application must include;




    1.     $100.00 License fee, made payable to the “State of Ohio Treasurer”.

    2.     $25,000 Bond executed in accordance with Section 3905.30 of the Ohio Revised Code.




                                        Accredited by the National Association of Insurance Commissioners (NAIC)
INS3245 (Rev. 09/2009)                                                                                                                       Page 1 of 2
Ohio Department of Insurance                                                          SURPLUS LINES BROKER LICENSE APPLICATION



                                          SURPLUS LINE BROKER’S BOND
                               AS PROVIDED BY SECTION 3905.35, REVISED CODE OF OHIO

                                                                         Bond Number
KNOWN ALL MEN BY THESE PRESENTS;

        That we,                                                                                           as principal, and
                                                                             surety, are held firmly bound unto the State of
Ohio in the sum of Twenty-five Thousand ($25,000) Dollars, for the payment of which sum, will and truly to be made, we
hereby jointly and severally bind ourselves, our heirs, executors and administrators, successors and assigns.

        Dated this                            day of                                       , 20

        The condition of the foregoing obligation is such that whereas the said
has made application to the Superintendent of Insurance for a license as a surplus line broker, in accordance with Section
3905.30 of the Ohio Revised Code, and is required by Section 3905.35 of the Ohio Revised Code to give bond payable to
said state, in the sum of Twenty-five Thousand ($25,000) Dollars, and conditioned as set forth in Section 3905.35 of the
Ohio Revised Code.

        NOW, THEREFORE, if such license is so issued to said
and then if he/she shall faithfully comply with Sections 3905.30 to 3905.35, inclusive, of the Ohio Revised Code, and shall
annually file with the Superintendent of Insurance in January, a sworn statement of the gross premiums charged for
insurance procured or placed, and the gross premiums on such insurance canceled under such license during the year
ending on the thirty-first day of December last preceding, and at the time of filing such statement shall pay to said
Superintendent as amount equal to five (5) percent of the balance of such gross premiums after deducting such return
premiums so reported, then the said obligation shall become void, otherwise it shall remain in full force and effect in law.

             IN TESTIMONY WHEREOF, said parties have hereunto set their hands the day and year aforesaid.

Witnesses:



                                                                        Principal


                                                                        Surety


COPY OF THE POWER OF ATTORNEY EVIDENCING AUTHORITY OF THE SIGNER OF THE BOND MUST BE
ATTACHED




                               Accredited by the National Association of Insurance Commissioners (NAIC)
INS3245 (Rev. 09/2009)                                                                                               Page 2 of 2

								
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