State of North Carolina
FINANCIAL EVALUATION DIVISION
COMPANY ADMISSIONS SECTION
N.C. DOMESTIC INSURER’S APPLICATION FOR LICENSE
A / The______
( Name of Company )
located in the City of ______and the State of North Carolina
has mailing address of ______.
. / The Company’s President ( ______) and the Company’s Secretary
( ______) hereby apply for a company license to do in North Carolina the business of insurance as indicated on the accompanying page. The license would continue in force and in effect subject to timely payment of the annual license continuation fee in accordance with North Carolina General Statute 58-6-7 and subject to any other applicable provision of the insurance laws of North Carolina.
. / We the President and the Secretary of the Company named above do solemnly swear the Company hereby accepts in good faith the terms and obligations of the Insurance laws of North Carolina as a part of the consideration of the Company’s license, and the Company has neither directly nor indirectly violated any of the provisions of the said Insurance laws and of all acts amendatory or supplementary thereto. It is understood and agreed that said license, if issued, may be revoked as provided in said laws.
B / .
. / President’s Signature / . / Secretary’s Signature
. / Print or Type
Pres. Name à / . / Print or Type
Sec . Name à
. / Month: / Day: / Year: / . / Month: / Day: / Year:
C / Sworn to and subscribed before me, this the ______day of ______, in year of ______
Notary’s Seal /
Notary Public à
My Commission expires à
D / FOR NCDOI INSURANCE DEPARTMENT USE ONLY
. / LICENSE NUMBER ( ON LICENSE SIGNED BY COMMISSIONER ) : / Effective Date of License :
. / LICENSING FEE
. / The licensing fee statutes, NCGS 58-6-5, 58-6-7, etc. were revised as of January 1, 2006 to implement the amounts indicated in “a, b” below. The company submits when due an initial licensing fee ( ILF ) and, submits when due an annual license continuation fee ( ALCF ) in the same amount as the ILF.
. / a. ______$ 500 as of 1-01-06 for fraternal order insurance companies . ( Prior fee was $100 ) .
. / b. ______$ 1,500 as of 1-01-06 for all other insurance companies ( except, “domestic farmers mutual assessment fire insurance companies and, mutual burial associations” ) . ( Prior fee was up to $1,100 ) .
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/ NORTH CAROLINA DEPARTMENT OF INSURANCE
FINANCIAL EVALUATION DIVISION
COMPANY ADMISSIONS SECTION
CONT. - N.C. DOMESTIC INSURER’S APPLICATION FOR LICENSE
Kinds of business as authorized and defined in North Carolina General Statute 58-7-15. Indicate by check (X) lines for which application is made. Each company should make application as far as possible within its primary subdivision. If applying for any line not contained within that subdivision, multiple line requirements must be met. If a desired line appears in two divisions, application shall be made only once.
LIFE
( ) l. Life insurance, including industrial sick benefit insurance
2. Annuities
( ) a. Annuities (excluding variable annuities)
( ) b. Variable annuities
( ) c. Variable life insurance
3. Accident and health insurance, including hospitalization
( ) a. Cancelable
( ) b. Non-cancelable
( ) c. Credit-Small loans
( ) d. Credit-Other than small loans / CASUALTY
3. Accident and health insurance, including hospitalization
( ) a. Cancelable
( ) b. Non-cancelable
( ) c. Credit-Small loans
( ) d. Credit-Other than small loans
6. Water damage (including sprinkler leakage)
( ) a. Commercial
( ) b. Residence
( ) 7. Burglary and theft insurance
( ) 8. Glass insurance
( ) 9. Boiler and machinery insurance
( ) 10. Elevator insurance
FIRE
*( ) 4. Fire insurance
5. Miscellaneous property insurance
( ) a. Extended coverage
( ) b. Growing crops
6. Water damage (including sprinkler leakage)
( ) a. Commercial
( ) b. Residence
( ) 7. Burglary and theft insurance
( ) 8. Glass insurance
( ) 11. Animal insurance
l2. Collision insurance
*( ) a. Automobile
( ) b. Other
l9. Motor vehicle and aircraft
*( ) a. Property damage
*( ) b. Fire
*( ) c. Theft
*( ) d. Comprehensive
*( ) e. Collision
20. Marine insurance
( ) a. Inland
( ) b. Ocean
( ) 2l. Marine protection and indemnity insurance
22. ( ) c. Other ______
/ ( ) 11. Animal insurance
l2. Collision insurance
*( ) a. Automobile
( ) b. Other
l3. Personal injury liability insurance
*( ) a. Automobile
( ) b. Other
l4. Property damage liability insurance
*( ) a. Automobile
( ) b. Other
*( ) 15. Workers’ compensation and
Employer’s liability insurance
( ) l6. Fidelity and surety insurance
( ) l7. Credit insurance
( ) l8. Title insurance
19. Motor vehicle and aircraft
*( ) a. Property damage
*( ) b. Fire
*( ) c. Theft
*( ) d. Comprehensive
*( ) e. Collision
( ) 2l. Marine protection and indemnity insurance
22. ( ) a. Aircraft Voluntary Settlement
( ) b. Hole-in-One
( ) c. Other ______
* License for any line so indicated requires membership in the North Carolina Rate Bureau.
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