DEPARTMENT OF BUSINESS & INDUSTRY - Nevada Division …
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|Probationary Sponsor’s Name & Address: |Probationary Licensee’s Name and Address: |DOI USE: |
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|License Number: |License Number: | |
|Telephone: |Telephone: | |
|E-Mail: |E-Mail: | |
|Pursuant to the Agreement To and Acknowledgement of Terms of Probation and Order in the matter of (Licensee), Cause no.: , you have |
|acknowledged that you will abide by the terms of the order. You are required to make the following report to the Commissioner by the due dates as indicated in the|
|order. During the final month of the order, you must set an appointment with the Division to discuss the individual’s compliance with Title 57 of the Nevada |
|Revised Statutes (NRS) and the Nevada Administrative Code (NAC) and whether a non-probationary license should be issued to (Licensee). |
|Failure to provide the required report could result in administrative action against both the Probationary licensee and the sponsor. |
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|Probationary report for (select) year 1 or year 2. Probationary license issued on . |
|Reporting period for year one: 1st Quarter , 2nd Quarter , 3rd Quarter , 4th Quarter or 11th month . |
|Pursuant to NRS 679B.159, any person who has knowledge of a violation of any provision of this code shall promptly report the facts and | |
|circumstances pertaining to the violation to the Commissioner. | |
|1. List the insurance duties of the probationary licensee (Attach additional sheets if necessary): | |
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|2. Did you directly and personally supervise the licensee in all of their activities during the probationary period? |Yes No |
|A “No” response requires a statement summarizing why you did not supervise. | |
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|A “Yes” response on the remaining questions requires a detailed statement summarizing the details. | |
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|While the licensee was under your supervision: | |
|3. Were there any verbal or written complaints made against the licensee during this quarterly probationary period? |Yes No |
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|4. Has the licensee been suspected of having misappropriated, converted or improperly withheld money or property received in the course of|Yes No |
|the business of insurance? | |
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|5. Has the licensee in any manner intentionally misrepresented the terms of an actual or proposed contract or application for insurance? |Yes No |
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|6. Has the licensee used fraudulent, coercive or dishonest practices, or demonstrated incompetence, untrustworthiness or financial |Yes No |
|irresponsibility in the conduct of business? | |
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|7. Is the licensee suspected of having forged another’s name to an application for insurance or any other document relating to the |Yes No |
|transaction of insurance? | |
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|8. Has the licensee knowingly accepted business related to insurance from an unlicensed person? |Yes No |
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|9. Has any contract or other business relationship with an insurance company terminated for any alleged misconduct (Be specific)? |Yes No |
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|10. Please describe the training the licensee has received during this quarterly period (Be specific). | |
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|11. Is there anything additional you would like to add (Attach additional sheets if necessary)? |Yes No |
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|PROBATIONARY SPONSOR AND PROBATIONARY LICENSEE’S ACKNOWLEDGEMENT |
| I hereby certify that, under penalty of perjury, all of the information submitted in this probationary report and attachments is true and complete. I am aware |
|that submitting false information or omitting pertinent or material information in connection with this report is grounds for administrative action and may subject |
|me to civil or criminal penalties. |
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|_______________________________________________ _____________________________________________ |
|Printed Name and Signature of Probationary Sponsor (date) Printed Name and Signature of Probationary Licensee (date) |
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|DOI USE: This correspondence must be directed to the Legal Section. |
|cc: Producer Licensing Section upon receipt. |
| year probationary license issued on . |
|Reporting period for year one: 1st Quarter , 2nd Quarter , 3rd Quarter , 4th Quarter or 11th month . |
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|Reviewed By: COMMENTS: |
NDOI 213 DOC 355 Probationary Insurance License Report (rev 4.4.2014)
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Department of Business and Industry
Nevada Division of Insurance
1818 E. College Pkwy, Suite 103, Carson City, Nevada 89706 Phone: (775) 687-0700 Fax: (775) 687-0787 Web: doi.
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