INSTRUCTIONS: CONNECTICUT INSURANCE PREMIUM FINANCE COMPANY LICENSE RENEWAL APPLICATION

To renew your Connecticut license to act as an insurance premium finance company, you must file the application discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Insurance Premium Finance Company License Renewal Application Step 1: Enter the company name on the first blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 2: Enter the company address on the second blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 3: Enter the name of a contact person on the third blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 4: Enter a contact phone number on the fourth blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 5: Enter the company federal tax identification number on the fifth blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 6: On line 1, indicate with a check mark whether the company has employees in Connecticut. If yes, you must attach a current certificate of worker's compensation insurance.

Connecticut Insurance Premium Finance Company License Renewal Application Step 7: Line 2 requires you to make a financial statement about the current financial condition of your company. Enter the date, your assets, liabilities, surplus and the total of your liabilities and surplus where indicated.

Connecticut Insurance Premium Finance Company License Renewal Application Step 8: Line 3 should be completed if your partnership, association or corporation has experienced changes in its partners, members or officers. Enter the full name of each new partner member or officer, their title (if they are an officer), their residential address, their business address and their occupation.

Connecticut Insurance Premium Finance Company License Renewal Application Step 9: Line 4 should completed if your corporation has experienced changes in directors. Enter the full name of each new director, their title (if an officer), their residential address, their business address and their occupation.

Connecticut Insurance Premium Finance Company License Renewal Application Step 10: If you have any new partners, directors, members or officers listed on lines 4 or 5, you must complete a separate biographical affidavit for each one. This is located on the third page.

Connecticut Insurance Premium Finance Company License Renewal Application Step 11: Sign and date the second page before a notary public.