California Insurance License

Form LIC 441-12: Business Entity Application for Administrator's Certificate

Mail 

$188

• A statement as to whether your organization is a California corporation, please include a photocopy of your Articles of Incorporation
• A list of all current corporate officers, including their complete home address. Please include a statement as to the percentage of stock ownership in the organization, if any.
• A list of all current directors of the organization, including their complete home address. Please include a statement as to the percentage of stock ownership in the organization, if any.
• A list of all current stockholders in the organization with complete home address, along with the percentage of stock ownership of 10% or more.
• A statement as to the number of employees employed by you or your organization. Please include the names of key employees who will assist in performing the tasks of an administrator with a brief statement as to their job assignments. Include an organization chart if it will assist in clarifying the organization structure.
• A copy of the formal written agreement, required by California Insurance Code Section 1759.1, between you or your organization and the insurers with whom you plan to do business. If your organization will not do business with insurers, explain who will indemnify the insured.
• A statement as to any bank facility, including complete address and account number, that has been selected in which you or your organization will maintain any fiduciary bank account required under Section 1759.6 of the Code.
• A statement as to any bank facility, including complete address and account number that has been selected in which you or your organization will maintain any claims payment bank account required under Section 1759.6 of the Code.
• A statement as to how you plan to conduct your business. Include the types of clients you anticipate will use your services as an administrator and the total number of insureds that you anticipate will be handled by your organization.
•  Corporations:  if already incorporated, attach a copy of your Certificate of Good Standing. If corporation
  has been formed as a result of a merger, submit a copy of your approved merger papers. 
• Limited Liability Company: attach a copy of your approved articles of organization. This documentation must be submitted with your application. 
• Background Information: If the answer is "yes" to any of these questions, you must submit the required documentation.
• Fingerprint Impressions: Fingerprint impressions are required for unlicensed applicants.
  •  Fingerprint impressions are required for all unlicensed applicants who have not held a license issued by this Department within the last 12 months. All business entities are required to submit fingerprint impressions of one officer, partner, manager, or member of the business entity.
• The Insurance Commissioner may require such other documents as will aid in determining whether the applicant meets the qualifications for a license.

Online

$188

Biennially by the end of the registration anniversary month.

Online

$311

Online

$0

Biennially by the end of the registration anniversary month.

Online

$311

Online

$0

Biennially by the end of the registration anniversary month.