Illinois department of financial and professional regulation 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by completing the applicant section. Enter your name exactly as it appears on your application or renewal form.
3. Fill in your date of birth, ensuring the format is MM/DD/YYYY.
4. Provide your complete address, including street, city, state, and ZIP code.
5. If you are a new applicant, refer to the reference sheet and record your profession name along with its three-digit profession code.
6. Enter your maiden or given surname if applicable.
7. For renewal applicants, list each individual license number you hold under relevant acts.
8. Input a daytime telephone number where you can be reached.
9. Sign and date the form to declare that all information provided is true and complete.
10. Have your authorized insurance agent complete their section before submitting the form with your application for licensure or renewal.

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