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Michigan insurance business entity affiliate disclosure

Lara form fis 0200-2025

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The document is an Insurance Business Entity Affiliate Disclosure form used to add or remove Designated Responsible Licensed Producers (DRLP) and affiliates associated with an insurance business entity. It requires the disclosure of various relationships, identification details of the business entity, changes in address, and information about affiliates including any legal issues they may have faced. The form also includes sections for signatures and certifications regarding compliance with state insurance laws.

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Begin with Part 1: Business Entity Identification. Fill in the Business Entity NAME, System ID Number, Tax ID Number (EIN), and National Producer Number (NPN). Indicate if this is a new business entity name by selecting 'Yes' or 'No'. If 'Yes', attach amended articles.
Provide the required Business Entity Email Address and Phone Number. Optionally, you can include a Fax Number.
In Part 1a, check if there is a new mailing or business address. If 'Yes', complete the Change of Business Entity Address section with the new details.
Proceed to Part 2: Affiliates. List any additions or changes for affiliates, including their names and SSN/FEIN numbers. Use additional pages if necessary.
Complete Part 3 by answering questions regarding any criminal convictions or administrative proceedings related to the affiliates being added.
In Part 4, if adding a new DRLP, ensure that the DRLP acknowledges their responsibilities by providing their name, title, and signature.
Finally, sign in Part 5 as required by a DRLP or authorized individual of the business entity. Ensure all information is accurate before submission.

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