Uniform Application for Individual Producer License/Registration Applicant Name: _________________________________________________ Jurisdiction and Type of License Requested Next to each jurisdiction, check the license type(s) and line(s) of authority for which you are applying. License Types: B Broker P - Producer SLP Surplus Lines Producer A Agent – – – P – Producer H Accident & – V Variable PL Personal – – of Authority: L Life Health or P Property C Casualty – – – Life/Variable Annuity Lines Sickness Limited Lines: Credit– Credit CR Car Rental CROP - Crop S Surety O Specify – – – T Travel – Type License Type Major Lines of Authority Limited Lines of Authority Jurisdiction A B P SLP V L H P C PL Credit CR CROP T S O ___________ AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VI VA
Uniform Application for Individual Producer License/Registration Applicant Name: _________________________________________________ Jurisdiction and Type of License Requested Next to each jurisdiction, check the license type(s) and line(s) of authority for which you are applying. License Types: P – Producer A – Agent B – Broker P - Producer SLP – Surplus Lines Producer of Authority: V – Variable Life/Variable Annuity L – Life H – Accident & Health or Sickness P – Property C – Casualty PL – Personal Lines Limited Lines: Credit– Credit CR – Car Rental CROP - Crop T – Travel S – Surety O – Specify Type License Type Major Lines of Authority Limited Lines of Authority Jurisdiction A B P SLP V L H P C PL Credit CR CROP T S O ___________ AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VI VA
committees_ex_pltf_plwg_individual_initial_producer_app_20132015_clean.docx