Application

Identification

The Iowa Insurance Division will not receive a copy of the application until it has been submitted with payment from the licensing coordinator.

First Name *

Middle Name

Last Name *

List any other names which you have used in the past

Date of Birth * Ex. MM/DD/YYYY

Social Security Number * Ex. 555-55-5555

Residence Address * Street address is required

City *

State *

Zip Code * Ex. 55555-5555

Home Phone * Ex. 555-555-5555

Business Phone * Ex. 555-555-5555

Email Address *

Affiliation/Examination Verification

Name of Iowa Licensed Rental Car Company applicant intends to affiliate with: *

Certification

I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of the license and may subject me to civil or criminal penalties. *

Unless provided otherwise by law or regulation of the jurisdiction , I hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to be my agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction is of the same legal force and validity as personal service upon myself. *

I further certify that I grant permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company. *

I authorize the jurisdictions to which this application is made to give any information concerning me, as permitted by law, to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information. *

I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure. *

I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or requested by the jurisdiction(s). *

I hereby swear, under penalty of perjury, that the statements made in this application and any attachments are true and correct and that I have read and understand the insurance laws of the State of Iowa related to the counter employee license. I designate the Insurance Commissioner to be my agent for service of process regarding all insurance disciplinary matters and agree that service upon the commissioner is of the same legal force and validity as personal service upon myself. I understand that this license will terminate automatically when my employment with the car rental company named in Part III terminates. *

Provide an email address of your licensing coordinator OR employer who will be responsible for submitting payment. Both you and the coordinator will receive a copy of this submission via email. * Note: Failure to provide an accurate email address will result in the rejection of this application.

Application

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