INSTRUCTIONS: CONNECTICUT INSURANCE PREMIUM FINANCE COMPANY LICENSURE APPLICATION

To apply for a license to act as an insurance premium finance company in Connecticut, file the application discussed in this article. This document can be obtained from the website maintained by the government of the state of Connecticut as part of a packet which includes additional power of attorney forms that will need to be completed.

Connecticut Insurance Premium Finance Company Licensure Application Step 1: On line 1, state whether the applicant is an individual, partnership, association or corporation.

Connecticut Insurance Premium Finance Company Licensure Application Step 2: On line 2, enter the name of the applicant.

Connecticut Insurance Premium Finance Company Licensure Application Step 3: On line 2a, enter the federal employer identification number of the applicant.

Connecticut Insurance Premium Finance Company Licensure Application Step 4: On line 3, enter the street address, city or town, state and zip code of the principal office.

Connecticut Insurance Premium Finance Company Licensure Application Step 5: On line 4, enter the street address, city or town, state and zip code of up to two Connecticut branch offices.

Connecticut Insurance Premium Finance Company Licensure Application Step 6: On line 5, write what other business is or will be conducted at principal or branch offices.

Connecticut Insurance Premium Finance Company Licensure Application Step 7: If the applicant is a corporation or LLC, enter the place and date of incorporation on line 6.

Connecticut Insurance Premium Finance Company Licensure Application Step 8: If the applicant is a partnership, association or corporation, enter the names, title, business and home addresses and occupation of all partners, members or officers on line 7.

Connecticut Insurance Premium Finance Company Licensure Application Step 9: If the applicant is a corporation, enter the names, home and business addresses and occupation of all directors on line 8.

Connecticut Insurance Premium Finance Company Licensure Application Step 10: Lines 9 and 10 contain instructions for mandatory attachments.

Connecticut Insurance Premium Finance Company Licensure Application Step 11: Document your assets, liabilities and surplus on line 11.

Connecticut Insurance Premium Finance Company Licensure Application Step 12: Document each individual applicant as instructed on lines 12A through 12H.

Connecticut Insurance Premium Finance Company Licensure Application Step 13: Line 13 should be completed by corporations only.

Connecticut Insurance Premium Finance Company Licensure Application Step 14: Sign and date line 14.