NAIC Uniform Application for
Fees: Adding lines of authority $60. Adding Agency Affiliation $60 per affiliation.
Fees are payable to the Nevada Division of Insurance
Please check the box(s) that apply: ( Adding Lines of Authority ( Adding an Agency Affiliation
| Soc. Security Number | If applicable, NASD Individual Central Registration Depository (CRD) Number |
| Are you affiliated with a financial institution/bank? |
|Yes No |
| Last Name JR./SR. etc | First Name | Middle Name | Date of Birth |
| | | |(month) ____ (day) ____ (year)_____ |
| Residence/Home Address (Physical Street) | P.O. Box | City | State | Zip or Foreign Country |
| Home Phone Number | Gender (Circle One) | Are you a Citizen of the United States? (Check One) |
|( ) - |Male Female |Yes No (If No, of which country are you a citizen?) |
| | |(If No, you must supply work authorization) |
| List your Nevada License Number (s): |
| Business Address (Physical Street) | P.O. Box | City | State | Zip or Foreign Country |
| Business Phone Number | Business Fax Number | Business E-Mail Address | Business Web Site Address |
|( ) - |( ) - | | |
| Applicant’s Business Mailing Address | P.O. Box | City | State | Zip or Foreign Country |
| If Applicable, beginning date of residency in the State of Nevada: Nonresidents: “Home State” where you hold a |
|Resident License |
|_________Month __________Day __________Year __________________________________________ |
|Please mark the lines of authority you are adding: |
|Life____ Health____ Variable Annuity/Life____ Property____ Casualty____ Surety____ Personal Lines _______Limited Credit____ |
|Limited Fixed Annuities____. |
|Residents of Nevada: You must attach the original pre-licensing education certificate and original Pearson VUE test results. |
|Non-residents must hold the same lines of authority in their home state. |
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|The Division encourages the use of Sircon’s Compliance Express at nevada for submitting and processing individual affiliations or terminations. The|
|process is instantaneous and eliminates the necessity of the paper filing. |
| List your Current Insurance Agency Affiliations (if applicable): |
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|Fein # ____________________________ Name of Agency___________________________________________NV License Number(s): |
|Fein # ____________________________ Name of Agency___________________________________________NV License Number(s):____ |
|List the Insurance Agency Affiliations you are adding: |
|Fein # ____________________________ Name of Agency___________________________________________NV License Number(s): |
|Fein # ____________________________ Name of Agency___________________________________________NV License Number(s):____ |
|I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that |
|submitting false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of the |
|license and may subject me to civil or criminal penalties. I further certify that I grant permission to the Commissioner of Insurance to verify information with any|
|federal, state or local government agency, current or former employer, or insurance company. I authorize the Commissioner of Insurance to give any information |
|concerning me, as permitted by law, 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. |
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|___________________________________________________ |
|Original Applicant Signature (Date) |
NDOI 212 Doc 327A Individual Modification Form (rev 4.15.13)
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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.
Division Use Only: Fees: _________________ Check #: ___________Application ID#: ___________ IND ID#: ____________
Approved by:__________ Date:_____________ License No: ____________________ NV Resident Criminal History Report: __
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