NATION SAFE DRIVERS ARKANSAS COVER SHEET

NATION SAFE DRIVERS
ARKANSAS COVER SHEET
AGENCY/ PRODUCER MOTOR CLUB LICENSING/ APPOINTMENT REQUIREMENTS
1. AGENCY/AGENT APPOINTMENT- Use Application Form AID-LI-I48-Agency
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3. IF THE AGENCY AND AGENT DO NOT HAVE MOTOR CLUB CURRENTLY LISTED AS A LINE
OF AUTHORITY ON THE LICENSE, PLEASE SUBMIT A LETTER ON BUSINESS LETTER HEAD
STATING THAT YOU ALLOW THE STATE OF ARKANSAS TO ENDORSE MOTOR CLUB TO THE
LICENSES (see enclosed example).
4. If the resident representative and business entity do not have a P&C or credit license, they are required to
complete Form AID-LI-RP (Uniform Application for Arkansas Individual Resident Insurance Producer
License) and Form AID-LI-UBE Arkansas Resident Business Entity (Agency) Uniform License
Application, which can be found at http://www.insurance.arkansas.gov/License/forms.htm. As per Arkansas
Bulletin NO. 3-2006 a background check is required for all new licenses for resident producers.
5. All non-resident producers are required to have an individual and business entity P&C or credit license
from their domicile state. The business entity is also required to file a Certificate of Authority with the
Arkansas Secretary of State. The NAIC application for producer and business entity must be completed;
instructions and forms can be found at http://www.insurance.arkansas.gov/License/forms.htm.
6. Resident & non-resident producers can also apply online for their P&C or Credit license at www.nipr.com.
Nation Safe Drivers will pay all of the appointment fees with an exception of new licensing for both
resident and non-resident producers.
Resident P&C Licensing Fee: $35.00 (Business Entity)
$35.00 (Individual Producer)
$10.00 (Each Producer Affiliation over 1)
Non-Resident P&C Licensing Fee: $ 35.00 (Business Entity)
$ 35.00 (Individual Producer)
$ 30.00 (Each Producer Affiliation over 1)
Letter of Certification from Domicile State is required
Please make sure that with all new appointments you include the Agency full address, telephone number,
fax number and e-mail address.
Renewal date 7/30 each year
Mail all completed forms to:
Nation Safe Drivers
Licensing & Compliance Dept
800 Yamato Road, Suite 100
Boca Raton, Fl. 33431
Revised 02/13/2013
FORM AID-LI-I48-AGENCY (2/05)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1200 WEST 3RD STREET
LITTLE ROCK, AR 72201
PHONE: 501-371-2750
FAX: 501-683-2604
AID-LI-I48-AGENCY APPOINTMENT
Nation Motor Club, Inc. DBA Nation Safe Drivers
Name of Insurance Company: _____________________________________________________________________
M0000
Company NAIC Number: _______________
Company Mailing Address: ______________________________________________________________________
800 Yamato Road, Suite 100
Boca Raton
FL
33431
P.O. Box or Street
City
State
Zip
Agency Tax Identification Number: _______________
Agency Name:
____________________________________________________________________________________________________
Agency Address: ______________________________________________________________________________
P.O. Box or Street
City
State
Zip
Appointed for Lines of Authority:_________________________________________________________________
Agents to be appointed under the Agency Appointment:
(Attach additional sheet if more agent’s are to be listed.)
________________ _________________________________ ___________________________ ___________
Agents SS#
Agent’s Name
Lines of Authority
Residence State
________________ _________________________________ ___________________________ ___________
Agents SS#
Agent’s Name
Lines of Authority
Residence State
________________ _________________________________ ___________________________ ___________
Agents SS#
Agent’s Name
Lines of Authority
Residence State
________________ _________________________________ ___________________________ ___________
Agents SS#
Agent’s Name
Lines of Authority
Residence State
To the Insurance Commissioner, State of Arkansas: This is to verify that the person hereby named, after
investigation covering both character and fitness, has been duly appointed agent. We further recommend such
agent as competent and trustworthy.
Dated__________________________________________
_______________________________________
Authorized Company Representative
Andrew Smith - President
__________________________________________________________
Typed or Printed Name
I, the undersigned, Insurance Commissioner for the State of Arkansas, do certify that the insurer has submitted
to me satisfactory evidence that it has complied with all the requirements of the laws of the State of Arkansas
governing such companies, and I further certify that the agent has the authority to take risks and transact the
business for and in behalf of said company so far as they may be legally empowered and for as long as they may
be employed by the above agency.
Dated at Little Rock, Arkansas ______________________________
_______________________________________
Insurance Commissioner
THIS APPOINTMENT MUST BE RETURNED TO THE ARKANSAS INSURANCE
DEPARTMENT IN THE EVENT OF TERMINATION OR CANCELLATION.
Sample
JOHN SMITH INSURANCE
101 MAIN STREET
CITY, STATE, ZIP
DATE:
ATTENTION: PRODUCER’
SLI
CENSI
NG
ARKANSAS INSURANCE DEPARTMENT
PLEASE ADD MOTOR CLUB TO MY AGENCY LICENSE AND TO THE LICENSE OF (PRODUCER)
___________________________.
THANK YOU.
SINCERELY,
PRODUCER’
SNAME.