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Printable fis 0200 doc

Printable fis 0200 doc-2025

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The document is a form from the Department of Insurance and Financial Services for disclosing and updating information about insurance business entity affiliates, including Designated Responsible Licensed Producers (DRLPs). It requires details about the business entity, any changes in address, and information on affiliates such as owners and officers. The form also includes questions regarding criminal history and administrative proceedings related to the affiliates. Signatures from authorized individuals are required to certify the accuracy of the information provided.

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Begin with Part 1: Business Entity Identification. Fill in the Business Entity NAME, Tax ID Number (EIN), System ID Number, and National Producer Number (NPN). Indicate if this is a new business entity name by selecting 'Yes' or 'No'. Provide the required email and phone number.
If applicable, proceed to Part 1a for Change of Address. Select 'Yes' or 'No' regarding a new mailing or business address. If 'Yes', enter the complete new mailing and business address details.
In Part 2, list any affiliates or licensed producers being added or canceled. Include their names and SSN/FEIN as necessary. Ensure to check the appropriate boxes for additions or cancellations.
Complete Part 3 by answering questions related to criminal history and administrative proceedings for each affiliate being added. Attach required documentation if answering 'Yes'.
For adding a new DRLP, fill out Part 4 with the DRLP's name, title, date, and signature.
Finally, sign in Part 5 confirming that all information is accurate and compliant with regulations. Provide your name, title, date, and signature before submitting.

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