License Application

Gov2Go
Introducing Gov2Go®! Iowa Insurance Division is now offering Gov2Go® to give Iowans a more streamlined checkout process. Features include a shopping cart for multiple services, reminders, stored payments, and much more!

Please note: Shopping cart will allow only one of this form to be submitted at a time.

Complete the application, attach the exhibits listed and submit a non-refundable filing fee of $100.00.

Service Fee: All payments have a $1.50 IOWAcess fee and a $.09 epayment fee. Credit card payments have an additional credit card fee of 2.5% of the total.

Once payment is processed, the fee is nonrefundable. If you have questions regarding this form or the amount of your fee, please contact producer licensing at producer.licensing@iid.iowa.gov or 515-654-6565.

Type of Applicant *

New Application

Renewal Application

Licenses Requested *

Resident License

Nonresident License

Is this application being completed by an Authorized Signor? *

Yes

Demographic Information

National Producer Number If assigned

First Name *

Middle Name

Last Name *

Suffix

Date of Birth *

Social Security Number * Ex. 555-55-5555

Primary Email Address * Will be used for all communications.

Additional Email Address

Home Phone * Ex. 555-555-5555

Gender *

Male

Female

Are you a US Citizen? *

Yes

If no, which country are you a citizen of? You will also be required to provide proof of eligibility to work in the U.S.

Home Address

Address *

City *

State *

Zip Code * Ex. 55555-5555

Foreign Country

Mailing Address

Address *

P.O. Box

City *

State *

Zip Code * Ex. 55555-5555

Foreign Country

Business Information

Business Entity Name *

Address *

P. O. Box

City *

State *

Zip Code * Ex. 55555-5555

Foreign Country

Phone * Ex. 555-555-5555

Phone Ext.

Fax Machine Ex. 555-555-5555

Email *

Web Site Address

Aliases or Trade Names

a. List any other assumed, fictitious, alias, maiden or trade names which you have used in the past.
b. List any trade names under which you are currently doing business or intend to do business.
(May be subject to state approval)

Aliases or Trade Names

Alias or trade name

Add Alias

Agency or Business Entity Affiliations

List your Insurance Agency Affiliations

FEIN

NPN

Name of Agency

Add Item

Employment History

Employment History *

Select Add Employment after each employer. You must enter a full 5years employment history.

Name *

City *

State *

Foreign Country

From Month *

From Year * Ex. 2020

To Month *

To Year * Ex. 2020

Position Held *

Add Employment

Provide the total number of months employed entered above *

I attest that the employment history submitted includes 5 years of history and is accurate to the best of my knowledge. *