California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 3 - Insurers
Article 12.9 - Life Settlements
Section 2548.25 - Business Entity Endorsement Form
State of California
Department of Insurance
Business Entity Endorsement
LIC 411-8A (Rev 04/2014)
___________________________
Producer Licensing Bureau
P.O. Box 1139
Sacramento, CA 95812-1139
(916) 322-3555 or (800) 967-9331
Pursuant to Section 1627 and 1661 of the Insurance Code
License Number of Business Entity: ____________________
| Business Entity Name: |
| Mailing Address: |
| City, State, Zip: |
To the Insurance Commissioner of the State of California: Effective from the date of filing this notice, the Business Entity hereby endorses the person(s) named to exercise the agency or brokerage powers of the business entity.
Note: Enter only one endorsement type per line. (Exception SL/SP)
*AH - Accident and Health Agent *LO - Life-Only Agent LI - Life-Limited to the Payment of Funeral & Burial Expenses
FX - Fire/Casualty Broker-Agent AU - Limited Lines Automobile Insurance Agent LA - Life and Disability Analyst
CS - Cargo Shipper's Agent **CI - Credit Insurance Agent PL - Personal Lines Broker Agent MC - Motor Club Agent
SL - Surplus Line Broker SP - Special Lines' Surplus Line Broker SL/SP - Surplus Line & Special Lines' Surplus Line Broker *** LS - Life Settlement Broker
| Endorsement Type** | Endorsee's Social Security Number**** | Endorsee's Name (as shown on license) | Effective Date of Endorsement | |
| 1. | ||||
| 2. | ||||
| 3. | ||||
| 4. | ||||
| 5. | ||||
| 6. | ||||
| 7. | ||||
| 8. | ||||
| 9. | ||||
| 10. |
Signature and title of authorized representative.
| - | Title: | Date: |
| E-mail: | Phone Number: () |
Filing fee: Submit $26 filing fee per endorsement type. Enter number of endorsements: __________ X $26 __________
Please Note: If you are endorsing an applicant for an insurance license, submit only one name per form and attach the form to the application.
| 1. | If you are submitting only an endorsement: | California Department of Insurance |
| Mail Endorsement form and fee to - | P.O. Box 957 | |
| or | Sacramento, CA 95812-0957 | |
| 2. | If endorsement is being submitted with original application | California Department of Insurance |
| Mail Endorsement form with application and fee to - | P.O. Box 1139 | |
| Sacramento, CA 95812-1139 |
* If endorsing both Accident and Health Agent and Life-Only Agent submit only one filing fee.
** For Credit Insurance applicants only: submit $34 per endorsement.
***There is no fee for the Life Settlement Broker.
****Disclosure of your U. S. social security number is mandatory pursuant to Cal. Civil Code, § 1798.17; Cal. Family Code, § 17520(d); and Federal Privacy Act of 1974, §§ 7(a) (2) (B) and 7(b). Your social security number will be used primarily for purposes of processing your application, including conducting any necessary investigation into your background. If you fail to disclose your social security number, your application will not be reviewed. An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone (800-967-9331) or by mail, to the following address: 320 Capitol Mall, Sacramento CA 95814.
1. New section
filed 7-29-2010 as an emergency; operative 7-29-2010. Emergency regulation shall
remain in effect, not to be repealed by the Office of Administrative Law, unless
repealed by the Department of Insurance pursuant to Insurance Code section
10113.35
(Register 2010, No. 31).
2. Change without regulatory effect amending
NOTE filed 1-24-2012 pursuant to section
100, title 1, California Code of
Regulations (Register 2012, No. 4).
3. Change without regulatory effect
amending form and NOTE filed 7-3-2013 pursuant to section
100, title 1, California Code of
Regulations (Register 2013, No. 27).
4. Change without regulatory effect
amending form filed 8-14-2014 pursuant to section
100, title 1, California Code of
Regulations (Register 2014, No. 33).
5. Renumbering of former section
2548.25 to section
2548.26 and renumbering of former
section 2548.24 to new section 2548.25 filed
11-25-2014; operative 1-1-2015 (Register 2014, No.
48).
Note: Authority cited: Sections 10113.35 and 12978, Insurance Code; CalFarm Ins. Co. v. Deukmejian, 48 Cal.3d 805 (1989); 20th Century Ins. Co. v. Garamendi, 8 Cal.4th 216 (1994). Reference: Sections 10113.1 and 10113.2, Insurance Code.
