Commonwealth of Massachusetts
DIVISION OF BANKS
1000 WASHINGTON STREET, 10TH FLOOR
BOSTON, MA 02118
INSURANCE PREMIUM FINANCE COMPANY
2011 License Renewal Instructions
The completed renewal application package must be received by the Division of Banks (Division) no later than
October 31, 2010. Renewal notice invoice(s) for your Insurance Premium Finance Company are enclosed. Please
note that the completed forms and the renewal payment are to be sent to different addresses.
Renewal applications and/or license fees received by the Division after the license expiration date of December 31, 2010
will be considered as new applications. This will require an additional payment of $300.00, noted on the renewal notice
invoice as an Investigative Fee. All documents requested of new applicants would also be required. In addition,
operations must cease if a licensee fails to submit a complete renewal package prior to the license expiration date.
The following are instructions for each document to be included in a complete renewal package:
1) RENEWAL WORKSHEET and RENEWAL APPLICATION
Review, edit (if necessary), and return the enclosed Renewal Worksheet. The Renewal Worksheet is a print-
out of information the Division has on record for your company. You should revise and update any inaccurate
information before you return the worksheet to the Division.
Download the License Renewal Application at the Division‟s web site at www.mass.gov/dob, by clicking on
„Apply for or Amend a License‟ under „Online Services‟, and following the links.
Fill out the License Renewal Application completely on the computer prior to printing and have notarized
All questions must be answered. If any question is not applicable, insert “N/A” or “Not Applicable” and state
the reason it does not apply. Complete the addendum to question #6. If addenda is necessary to complete
questions #5 or #7 - #12, please number each addendum to conform to the application question.
If you do not plan to renew your company‟s license(s), you should complete the enclosed Renewal Worksheet
by checking off “Do Not Renew” and return the Renewal Worksheet along with your original license(s). The
Division thereafter will send to you an Affidavit of No Activity, which you will be required to sign and return.
2) MASSACHUSETTS CORPORATION ANNUAL REPORT
Corporations and Limited Liability Companies must provide a copy of the licensee‟s most recent
MASSACHUSETTS CORPORATION ANNUAL REPORT (LLC Annual Report for limited liability
companies) as submitted to the Massachusetts Office of the Secretary of the Commonwealth.
3) RECORD KEEPING PLAN
Any Insurance Premium Finance Company that has relocated its office outside of Massachusetts during the
past twelve months is required to file a Record Keeping Plan, pursuant to 209 CMR 48.00 et seq. The Record
Keeping Plan is available on the Division‟s website, www.mass.gov/dob, by clicking on „Apply for or Amend a
License‟ under „Online Services‟, and following the links. If your company notified the Division of an address
change and, if relevant, supplied a Record Keeping Plan to the Division in the past twelve months, you are not
required to resend those documents.
4) FINANCIAL STATEMENTS
Insurance Premium Finance Companies must submit unconsolidated entity-only financial statements, which
have been audited or reviewed by an independent Certified Public Accountant, within 120 days of the close
of its most recent fiscal year. The financials must be prepared on an accrual basis, in accordance with generally
accepted accounting principals GAAP.
Also submit your company‟s most recent interim financial statements, dated no earlier than September 30,
2010 or August 31, 2010. These financials may be internally-prepared, and signed and dated by an officer,
director or member of the licensee. The financials must been prepared on an accrual basis, in accordance with
(GAAP). FINANCIAL STATEMENTS PREPARED ON A CASH OR INCOME TAX BASIS WILL
NOT BE ACCEPTED.
5) CRIMINAL BACKGROUND CHECK ***PLEASE READ CAREFULLY***
For a list of those individuals required to complete and submit CORI REQUEST FORMs (CORI form) please
refer to the guidelines provided on the CORI Addendum sheet (Addendum Sheet). You must complete and
submit this addendum sheet with the CORI forms.
A separate CORI form must be completed and signed by each individual listed on the Addendum Sheet.
Please note that the CORI form must be notarized and you are required to submit a legible copy of a
government issued photographic form of identification with each CORI form. CORI forms and addenda which
are not typewritten or clearly printed, as well as IDs that are not legible, will be returned to you for clarification
and will delay the renewal process. The CORI form is available on the Division‟s website at
www.mass.gov.dob, by clicking on „Apply for or Amend a License‟ under‟ „Online Services‟, and following
THE RENEWAL APPLICATION WITH ADDENDA, RENEWAL WORKSHEET, MASSACHUSETTS
CORPORATION ANNUAL REPORT, FINANCIAL STATEMENTS, CORI REQUEST FORM AND CORI
ADDENDUM WORKSHEET MUST BE RECEIVED BY THE DIVISION NO LATER THAN OCTOBER 31,
Division of Banks
Non-Depository Institution Supervision Unit
1000 Washington Street, 10th Floor
Boston, MA 02118
Attn: Nicole Bullock, Licensing Examiner
Please note that only the aforementioned license renewal requirements should be sent to the above address.
6) RENEWAL NOTICE INVOICE(S)
Detach the remittance portion(s) and send with a check for the aggregate license fee(s), payable to the
Commonwealth of Massachusetts. Mail (First Class only) remittance and check in the enclosed envelope to:
Division of Banks
P.O. Box 3952
Boston, MA 02241-3952
Note: To ensure timely license renewal, the remittances should be mailed at least thirty (30) days prior to the
license expiration date. DO NOT SEND OR DELIVER RENEWAL NOTICE INVOICE(S) AND
REMITTANCES TO 1000 WASHINGTON STREET.
7) IMPORTANT INFORMATION
Failure to pay license fees, examination/inspection fees, or late fees for annual reports may result in non-
renewal of licenses.