NATION SAFE DRIVERS ARKANSAS COVER SHEET AGENCY/ PRODUCER MOTOR CLUB LICENSING/ APPOINTMENT REQUIREMENTS 1. AGENCY/AGENT APPOINTMENT- Use Application Form AID-LI-I48-Agency 2. Su bmi taCLEARc opyoft heBus i n e s sEnt i t y ’ sc ur r e ntI ns ur a n c eLi c e n s e . 3. IF THE AGENCY AND AGENT DO NOT HAVE MOTOR CLUB CURRENTLY LISTED AS A LINE OF AUTHORITY ON THE LICENSE, PLEASE SUBMIT A LETTER ON BUSINESS LETTER HEAD STATING THAT YOU ALLOW THE STATE OF ARKANSAS TO ENDORSE MOTOR CLUB TO THE LICENSES (see enclosed example). 4. If the resident representative and business entity do not have a P&C or credit license, they are required to complete Form AID-LI-RP (Uniform Application for Arkansas Individual Resident Insurance Producer License) and Form AID-LI-UBE Arkansas Resident Business Entity (Agency) Uniform License Application, which can be found at http://www.insurance.arkansas.gov/License/forms.htm. As per Arkansas Bulletin NO. 3-2006 a background check is required for all new licenses for resident producers. 5. All non-resident producers are required to have an individual and business entity P&C or credit license from their domicile state. The business entity is also required to file a Certificate of Authority with the Arkansas Secretary of State. The NAIC application for producer and business entity must be completed; instructions and forms can be found at http://www.insurance.arkansas.gov/License/forms.htm. 6. Resident & non-resident producers can also apply online for their P&C or Credit license at www.nipr.com. Nation Safe Drivers will pay all of the appointment fees with an exception of new licensing for both resident and non-resident producers. Resident P&C Licensing Fee: $35.00 (Business Entity) $35.00 (Individual Producer) $10.00 (Each Producer Affiliation over 1) Non-Resident P&C Licensing Fee: $ 35.00 (Business Entity) $ 35.00 (Individual Producer) $ 30.00 (Each Producer Affiliation over 1) Letter of Certification from Domicile State is required Please make sure that with all new appointments you include the Agency full address, telephone number, fax number and e-mail address. Renewal date 7/30 each year Mail all completed forms to: Nation Safe Drivers Licensing & Compliance Dept 800 Yamato Road, Suite 100 Boca Raton, Fl. 33431 Revised 02/13/2013 FORM AID-LI-I48-AGENCY (2/05) ARKANSAS INSURANCE DEPARTMENT LICENSE DIVISION 1200 WEST 3RD STREET LITTLE ROCK, AR 72201 PHONE: 501-371-2750 FAX: 501-683-2604 AID-LI-I48-AGENCY APPOINTMENT Nation Motor Club, Inc. DBA Nation Safe Drivers Name of Insurance Company: _____________________________________________________________________ M0000 Company NAIC Number: _______________ Company Mailing Address: ______________________________________________________________________ 800 Yamato Road, Suite 100 Boca Raton FL 33431 P.O. Box or Street City State Zip Agency Tax Identification Number: _______________ Agency Name: ____________________________________________________________________________________________________ Agency Address: ______________________________________________________________________________ P.O. Box or Street City State Zip Appointed for Lines of Authority:_________________________________________________________________ Agents to be appointed under the Agency Appointment: (Attach additional sheet if more agent’s are to be listed.) ________________ _________________________________ ___________________________ ___________ Agents SS# Agent’s Name Lines of Authority Residence State ________________ _________________________________ ___________________________ ___________ Agents SS# Agent’s Name Lines of Authority Residence State ________________ _________________________________ ___________________________ ___________ Agents SS# Agent’s Name Lines of Authority Residence State ________________ _________________________________ ___________________________ ___________ Agents SS# Agent’s Name Lines of Authority Residence State To the Insurance Commissioner, State of Arkansas: This is to verify that the person hereby named, after investigation covering both character and fitness, has been duly appointed agent. We further recommend such agent as competent and trustworthy. Dated__________________________________________ _______________________________________ Authorized Company Representative Andrew Smith - President __________________________________________________________ Typed or Printed Name I, the undersigned, Insurance Commissioner for the State of Arkansas, do certify that the insurer has submitted to me satisfactory evidence that it has complied with all the requirements of the laws of the State of Arkansas governing such companies, and I further certify that the agent has the authority to take risks and transact the business for and in behalf of said company so far as they may be legally empowered and for as long as they may be employed by the above agency. Dated at Little Rock, Arkansas ______________________________ _______________________________________ Insurance Commissioner THIS APPOINTMENT MUST BE RETURNED TO THE ARKANSAS INSURANCE DEPARTMENT IN THE EVENT OF TERMINATION OR CANCELLATION. Sample JOHN SMITH INSURANCE 101 MAIN STREET CITY, STATE, ZIP DATE: ATTENTION: PRODUCER’ SLI CENSI NG ARKANSAS INSURANCE DEPARTMENT PLEASE ADD MOTOR CLUB TO MY AGENCY LICENSE AND TO THE LICENSE OF (PRODUCER) ___________________________. THANK YOU. SINCERELY, PRODUCER’ SNAME.