The Arkansas Aid Li Tagy form is a document required by the Arkansas Insurance Department for businesses seeking to obtain a title agency license. This form collects essential information about the business entity, its owners, and any relevant legal history. Completing this form accurately is crucial for compliance with state regulations and to facilitate the licensing process.
The Arkansas Aid Li Tagy form serves as a crucial document for businesses seeking to navigate the licensing landscape within the state’s insurance sector. This form is designed to gather essential information about the business entity, including its name, structure, and contact details. Applicants must provide their Federal Employer Identification Number (FEIN) and, if applicable, their National Producer Number. The form also requires a thorough disclosure of any assumed or fictitious names under which the business operates. Furthermore, it delves into the background of the entity’s owners, partners, and officers, asking for detailed identification and social security numbers for those with significant ownership interests. The form outlines the specific type of license or registration being sought, ensuring that applicants indicate their legal business type—whether a corporation, partnership, or limited liability company. Additionally, it includes a series of questions aimed at uncovering any past legal issues that could impact the business's ability to obtain a license, such as criminal convictions or administrative proceedings. By requiring a certification and attestation from the entity’s leadership, the form emphasizes the importance of honesty and transparency in the application process. Completing this form accurately is vital for compliance with Arkansas insurance regulations and for establishing a trustworthy reputation in the industry.
The Arkansas Aid Li Tagy form is designed for business entities seeking to obtain a license or registration to operate as a title agency within the state of Arkansas. This form collects essential information about the business, its owners, and its operations. By providing this information, applicants can demonstrate their compliance with state regulations and ensure they meet the necessary requirements for licensure.
When filling out the Arkansas Aid Li Tagy form, you will need to provide various details, including:
Additionally, you must answer background questions related to criminal history, administrative proceedings, financial obligations, and any prior issues with insurance agency contracts. It’s crucial to provide accurate and complete information to avoid delays or complications in the application process.
If you answer "yes" to any of the background questions on the form, you must provide additional documentation. This includes:
Failure to provide this information can lead to delays in processing your application or potential denial of your license. Transparency is essential, as the licensing authority will review these details closely.
The completed Arkansas Aid Li Tagy form can be submitted via mail or fax. The mailing address is:
Arkansas Insurance Department License Division 1200 West 3rd Street Little Rock, AR 72201
For fax submissions, use the number: 501-683-2604. Ensure that all required documents are attached, and signatures are included where necessary. Double-check the form for accuracy before submission to facilitate a smooth review process.
FORM AID-LI-TAGY (9/07)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1200 WEST 3RD STREET
LITTLE ROCK, AR 72201
PHONE: 501-371-2750
FAX: 501-683-2604
TITLE AGENCY
(Please Print or Type)
1
Business Entity Name
2 Incorporation/Formation
3 FEIN
Date
-
4
If assigned, National Producer Number (NP#)
5 If applicable, NASD Firm Central Registration Depository (CRD) Number
6List any other assumed, fictitious, alias or trade names under which you are doing business or intend to do business.
7State of Domicile
8Country of Domicile
9 Is the business entity affiliated with a financial institution/bank?
Yes
No
10Business Address
11City
12State
13Zip Code
14Foreign Country
15
Phone Number
16 Fax Number
17 Business Web Site Address
18 Business E-Mail Address
(
)
19
Mailing Address
20
P.O. Box
21 City
22 State 23 Zip Code
24Foreign Country
Designated/Responsible Licensed Title Agent
25Identify all Licensed Title Agents:
Name
SSN
Owners, Partners, Officers and Directors
26Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity:
Title
SSN/FEIN
Owner: Yes / No
(State Use)
Form AID-LI-TAGY(9/07)
Page 2
Jurisdiction and Type of License/Registration Requested –
27Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.
Legal Business Type:
C – Corporation
P – Partnership
LLC – Limited Liability Company
LLP – Limited Liability Partnership
Background Information
28Please read the following very carefully and answer every question. All copies of documents must be certified. All written statements submitted by the Applicant must include an original signature.
1. Has the business entity or any owner, partner, officer or director ever been convicted of, or is the business entity or any owner, partner,
Yes ___
No___
officer or director currently charged with, committing a crime, whether or not adjudication was withheld?
“Crime”
includes a misdemeanor , felony or a military offense. You may exclude misdemeanor traffic citations and juvenile offenses.
“Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo
contendre, or having been given probation, a suspended sentence or a fine.
If you answer yes, you must attach to this application:
a)
a written statement explaining the circumstances of each incident,
b)
a
certified copy of the charging document, and
c)
certified copy of the official document which demonstrates the resolution of the charges or any final judgment
2. Has the business entity or any owner, partner, officer or director ever been involved in an administrative proceeding regarding any
professional or occupational license?
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine
, a cease and
desist order, a prohibition order, a compliance order,
placed on probation or surrendering a license to resolve an administrative
action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a
professional or occupational license. “Involved” also means having a license application denied or the act of withdrawing an
application to avoid a denial. You may EXCLUDE terminations due solely to noncompliance with continuing education
requirements or failure to pay a renewal fee.
a) a written statement identifying the type of license and explaining the circumstances of each incident,
b) a certified copy of the Notice of Hearing or other document that states the charges and allegations, and
c) a certified copy of the official document which demonstrates the resolution of the charges or any final judgment.
3.
Has any demand been made or judgment rendered against the business entity or any owner, partner, officer or director for overdue
monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding?
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment.
4.
Has the business entity or any owner, partner, officer or director ever been notified by any jurisdiction to which you are applying of any
delinquent tax obligation that is not the subject of a repayment agreement?
If you answer yes, identify the jurisdiction(s): _______________________________________
5. Is the business entity or any owner, partner, officer or director a party to, or ever been found liable in any lawsuit or arbitration proceeding
involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
a written statement summarizing the details of each incident,
a certified copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, and
a certified copy of the official document which demonstrates the resolution of the charges or any final judgment.
6. Has the business entity or any owner, partner, officer or director ever had an insurance agency contract or any other business relationship
with an insurance company terminated for any alleged misconduct?
a)a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license, and
b)certified copies of all relevant documents.
Page 3
Applicants Certification and Attestation
29The undersigned owner, partner, officer or director of the business entity hereby certifies, under penalty of perjury, that:
1.All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity to civil or criminal penalties.
2.Where required by law, the business entity hereby designates the Commissioner, Director or Superintendent of Insurance, or an appropriate representative in each jurisdiction for which this application is made to be its agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner or Director of that jurisdiction is of the same legal force and validity as personal service upon the business entity.
3.The business entity grants permission to the Commissioner or Director of Insurance in each jurisdiction for which this application is made to verify any information supplied with any federal, state or local government agency, current or former employer or insurance company.
4.Every owner, partner, officer or director of the business entity either a) does not have a current child-support obligation, or b) has a child-support obligation and is currently in compliance with that obligation.
5.I authorize the jurisdictions to give any information they may have concerning me 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.
6.I acknowledge that I understand and comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.
7.If required, I have received a Certificate of Good Standing from the jurisdiction's Secretary of State in which I am applying.
8.For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state.
Attachments
Must be signed by an officer, director, principal or partner of the business entity:
Month DayYear
____________________________________________
Signature
_________________________________________________
Typed or Printed Name
Social Security Number
Address
City
State
Zip
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When filling out the Arkansas Aid Li Tagy form, it’s essential to be thorough and precise. Here are seven important dos and don’ts to keep in mind:
Omitting Required Information: Many applicants fail to provide all necessary details. Each section of the form must be filled out completely. Missing information can delay processing or lead to rejection.
Incorrectly Identifying Owners and Officers: It's crucial to accurately list all owners, partners, and officers. Misidentifying or omitting individuals with significant interest can result in serious complications.
Neglecting to Attach Required Documents: Applicants often forget to include necessary attachments. Ensure that all requested documents, such as certified copies and written statements, are included with the application.
Failing to Sign the Application: A common oversight is not signing the application. The form must be signed by an authorized individual to be valid. Without a signature, the application cannot be processed.