BROKER LICENSE INDIVIDUAL REQUIREMENTS. The following are the basic requirements an applicant must satisfy to obtain a broker license:

(1)

BROKER LICENSE INDIVIDUAL REQUIREMENTS

An insurance certificate or license is required to solicit, sell, negotiate, or give advice regarding insurance contracts in the

Commonwealth of Pennsylvania. The Insurance Department is empowered by the Insurance Department Act of 1921, as

amended, to qualify individuals who wish to operate as agents. Title 31, Chapters 37 and 39 sets forth the lawful

standards and requirements for insurance agents and brokers.

The following are the basic requirements an applicant must satisfy to obtain a broker license:

1) be at least 18 years of age;

2) maintain a business or legal address in the Commonwealth of Pennsylvania;

3) be able to read and write in the English language;

4) pass the appropriate examination(s) required by statute or meet the examination exemption requirement

(31 Pa. Code § 37.23) or if non-resident, provide proof of licensure in good standing in home state for the

same line of authority for which applying;

5) possess the requisite professional competence, general fitness and integrity of character; and

6) the applicant is not an employee of a public utility that conducts business in Pennsylvania.

To apply for a broker license, an applicant must:

1) pass the appropriate examination or provide proof that the applicant meets the examination exemption

requirements, i.e., provides a copy of a CPCU, CLU, or CIC designation diploma, or if non-resident,

provide letter of certification of good standing from home state;

Please note that pursuant to 31 Pa. Code § 37.25, to be eligible to take the broker’s examination for:

a) the property and casualty line of authority, you must be certified and appointed as an agent with both

property and casualty lines of authority or you must be currently licensed as a property and casualty

broker in another state; and

b) the life and accident and health lines of authority, you must be certified and appointed as an agent

with both the life and accident and health lines of authority or you must be currently licensed as a life,

accident and health broker in another state.

It is your responsibility to provide this information to the testing administrator.

2) complete a verified IDL-11 application (see IDL-11 Instructions);

3) make sure the appropriate fee is included with the application (a fee is not required for a broker that is

already licensed and is adding a line of authority); and

4) forward the completed application to the Insurance Department within the appropriate timeframe.

The application will be returned, if:

1) you do not meet the examination exemption requirements (31 Pa. Code § 37.23 and/or 37.24) and you

have not passed the appropriate examination;

2) your examination results are more than one year old (test results are valid for one year from the date of

the examination, 31 Pa. Code § 37.31(e));

3) the notary is more than 90 days old;

4) if non-resident, the letter of certification is more than 90 days old;

5) the appropriate fee, if required, is not included; and

6) the application is incomplete in any manner, including not providing required attachments and/or

explanations to the questions you answered in the affirmative.

COMMONWEALTH OF PENNSYLVANIA

INSURANCE DEPARTMENT

BUREAU OF PRODUCER LICENSING

1300 Strawberry Square Phone (717) 787-3840

Harrisburg, PA 17120 Fax (717) 787-8553

(2)

Page 2

To expedite processing, please make sure the application is complete and include a copy of your test scores, if

appropriate. If you meet all of the requirements to obtain a broker license and the Insurance Department has verified that

there is nothing in your background that should prohibit you from obtaining a license, the appropriate license will be

issued to you.

Additional information is available in the Pennsylvania Insurance Department Licensing Information Bulletin. This

Bulletin provides general guidelines regarding licensing and how to schedule an examination. The Bulletin is available by

contacting Experior Assessments, LLC, the Insurance Department’s testing vendor, at 1-800-715-2418 or visit Experior

Assessments’ website at www.experioronline.com. or by contacting the Bureau of Producer Licensing at the above

address and telephone number

Sincerely yours,

Bureau of Producer Licensing

(3)

INSTRUCTIONS FOR IDL-11

IDENTIFICATION- INCLUDE ALL INFORMATION UNDER THIS SECTION.

LAST NAME, FIRST NAME, MIDDLE INITIAL, SOCIAL SECURITY NUMBER, MAILING ADDRESS, RESIDENCE ADDRESS, AND BUSINESS ADDRESS. Please note that street address must be provided for the residence address; P.O. Boxes are not acceptable.

CERTIFICATE- CHECK THE ONE THAT APPLIES UNDER SECTION A. CHECK

TYPE AND STATUS- NEW BROKER IF YOU ARE NOT CURRENTLY LICENSED IN PENNSYLVANIA AS A

BROKER. CHECK EXISTING BROKER IF YOU ARE CURRENTLY LICENSED AS A

BROKER IN PENNSYLVANIA AND ADDING A LINE OF AUTHORITY.

CHECK THE ONE THAT APPLIES UNDER SECTION B. Resident is defined as a person

whose business address or legal residence is located in Pennsylvania. A nonresident is defined as

a person whose business and legal residence is outside of Pennsylvania.

Note: If nonresident, include a home state letter of certification, confirming that you are licensed

in the home state for the same line(s) of insurance being applied for, dated within 90 days of

filing. If currently licensed as a resident in another state and moving to Pennsylvania, include a

letter of clearance from your present or previous home state. Failure to provide such

documentation will result in the return of your application as incomplete.

LINES OF CHECK THE ONE THAT APPLIES UNDER SECTION A.

AUTHORITY-

CHECK THE LINES OF AUTHORITY FOR WHICH THE APPLICANT IS APPLYING UNDER

SECTION B.

TRADING NAMES-COMPLETE THIS SECTION, ONLY IF YOU ARE GOING TO USE A TRADING AS

NAME OR FICTITIOUS NAME. Include a copy of the Department of State approved

fictitious name filing or an explanation as to why you do not need to file the fictitious

name with the Pennsylvania Department of State.

ATTACHMENTS- CHECK ONLY THE ATTACHMENTS YOU ARE INCLUDING WITH THE APPLICATION.

APPLICATIONS WILL BE REJECTED IF REQUIRED ATTACHMENTS ARE NOT

INCLUDED.

MANDATORY THIS SECTION IS MANDATORY. INCLUDE CURRENT

EMPLOYMENT- EMPLOYER, ADDRESS, START DATE, END DATE AND

HISTORY OCCUPATION. IF LESS THAN TWO YEARS, INCLUDE PREVIOUS EMPLOYER.

HISTORY MUST INCLUDE TWENTY-FOUR MONTHS PRIOR TO DATE OF

APPLICATION.

MANDATORY ANSWER EACH QUESTION YES OR NO, AFTER READING

BACKGROUND CAREFULLY.AS REQUESTED FOR CERTAIN AFFIRMATIVE

INFORMATION- ANSWERS, INCLUDE EXPLANATIONS AND ATTACHMENTS. FAILURE TO PROVIDE

THE REQUIRED EXPLANATIONS OR ATTACHMENTS WILL RESULT IN YOUR

APPLICATION BEING RETURNED TO YOU AS INCOMPLETE.

MANDATORY THIS SECTION MUST BE COMPLETED BY A NOTARY PUBLIC,

APPLICANTS AND THE NOTARY PUBLIC CANNOT BE THE APPLICANT.

CERTIFICATION NOTARY DATE CANNOT BE OVER NINETY(90) DAYS OLD.

Remember to attach check or money order payable to the Commonwealth of Pennsylvania. Fees for resident broker

license is $40 and non-resident fees are reciprocal with home state. A fee is not required to add an additional line of

authority.

(4)

IDL 11 (01/12/00)

BROKER LICENSE APPLICATION

(Individual)

SOCIAL SECURITY NUMBER _____-_-_ DATE OF BIRTH _//_____

Month Date Year

FULL LEGAL NAME _____________________________________________________________________

Last Name First Name Middle Initial (Jr/Sr/III) (NOTE: THE FULL LAST NAME MUST BE USED-NO NICKNAMES. ANY TRADING NAMES MUST BE LISTED IN TRADING AS NAMES SECTION.)

MAILING ADDRESS _______________________________________________________________________________________________________ STREET

_______________________________________________________________________________________________________ CITY STATE ZIP CODE E-MAIL ADDRESS

RESIDENCE ADDRESS ______________________________________________________________________________________________________ (If different than above) STREET

_________________________________________________________________________ (_____)______________________ CITY STATE ZIP CODE HOME TELEPHONE NUMBER BUSINESS ADDRESS ______________________________________________________________________________________________________

STREET

(Street Address Required) ( )

CITY STATE ZIP CODE BUSINESS TELEPHONE NUMBER

*ALL ADDRESSES MUST BE PROVIDED AND PO BOXES ARE NOT ACCEPTABLE FOR RESIDENCE ADDRESS

A. CHECK ONE: B. CHECK ONE:

NEW BROKER (TEST REQUIRED) RESIDENT

EXISTING BROKER REQUESTING ADDITIONAL LINE CONVERSION TO RESIDENT

(ATTACH IN FORCE LICENSE-NOT A COPY)

(ATTACH HOME STATE CLEARANCE LETTER)

NONRESIDENT

(ATTACH LETTER OF CERTIFICATION DATED WITHIN 90 DAYS OF FILING)

A. CHECK ONE: B. CHECK THOSE THAT YOU ARE APPLYING FOR:

PASSED EXAMINATION 1100 LIFE, ACCIDENT AND HEALTH

(SCORES VALID FOR ONE YEAR)

1200 PROPERTY AND CASUALTY

PROFESSIONAL DESIGNATION

NOTE: CERTAIN REQUIREMENTS MUST BE MET SUCH AS HOLDING AN AGENT’S CERTIFICATE

(ATTACH PROOF) OF QUALIFICATION OR BROKERS LICENSE TO QUALIFY TO SUBMIT THIS APPLICATION.

IF THE APPLICANT TRANSACTS BUSINESS UNDER AN ASSUMED TRADE NAME, PROVIDE THE FULL NAME IN THE SPACE PROVIDED. IF NO ASSUMED TRADE NAME IS USED, LEAVE BLANK, INDIVIDUALS CANNOT ASSUME THE NAME OF A CORPORATION OR PARTNERSHIP.

• LETTER OF CERTIFICATION DATED WITHIN 90 DAYS OF FILING NEEDED BY NONRESIDENTS

• LETTER OF CLEARANCE NEEDED TO CONVERT TO A RESIDENT

• DEPARTMENT OF STATE APROVED FICTITIOUS NAME FILING

• AFFIDAVIT IF YES RESPONSE TO QUESTION 4d * OTHER_____________________________________________

IDL-11

PART II CERTIFICATE TYPE AND STATUS

PART III LINES OF AUTHORITY

PART IV TRADING NAMES

COMMONWEALTH OF

PENNSYLVANIA

INSURANCE DEPARTMENT

BUREAU OF PRODUCER LICENSING

PART I IDENTIFICATION

PART V ATTACHMENTS

(5)

IDL 11 (01/12/00)

SOCIAL SECURITY NUMBER AS PROVIDED ON REVERSE SIDE __________-______-_________ IDL-11 ATTACH YOUR CHECK OR MONEY ORDER FOR THE FEE TO THIS COMPLETED APPLICATION.

FAILURE TO INCLUDE PROPER PAYMENT WILL RESULT IN REJECTION OF THE APPLICATION. CHECK AMOUNT $_______________CHECK NO.___________

NOTE: FEES: RESIDENT-$40 FOR INDIVIDUAL OR ACTIVE OFFICER; NON-RESIDENT-RECIPROCAL WITH HOME STATE

YES NO

1. DO YOU NOW HOLD OR HAVE YOU EVER HELD A RESIDENT INSURANCE LICENSE IN ANY OTHER STATE OR CANADA? (IF YES AND THE LICENSE IS STILL IN FORCE, ATTACH A HOME STATE LETTER OF CERTIFICATION. IF THE LICENSE IS NOT IN FORCE, ATTACH A CLEARANCE LETTER FROM THE STATE WHERE YOU LAST HELD A RESIDENT LICENSE.)

2. HAVE YOU EVER BEEN PENALIZED OR FINED, HAD A LICENSE REFUSED, SUSPENDED OR REVOKED BY THIS DEPARTMENT OR THE INSURANCE DEPARTMENT OF ANY OTHER STATE OR PROVIDENCE OF CANADA OR IS ANY SUCH ACTION NOW PENDING? (IF YES, PROVIDE A FULL EXPLANATION ON A SEPARATE SHEET OF PAPER.)

3. HAVE YOU EVER BEEN CONVICTED OF OR PLED NOLO CONTENDERE (NO CONTEST) TO ANY MISDEMEANOR OR FELONY OR CURRENTLY HAVE PENDING MISDEMEANOR OR FELONY CHARGES FILED AGAINST YOU? (IF YES, GIVE DATE, NAME AND ADDRESS OF COURT, TYPE OF CHARGE (i..e. FELONY), BASIS OF CHARGE AND OUTCOME OR SENTENCE AND INCLUDE A CERTIFIED COPY OF THE COURT RECORD.)

4. ARE YOU AN OFFICER OR EMPLOYEE OF A FINANCIAL INSTITUTION AS DEFINED BY ACT 40, SECTION 601 (40 P.S. §231) OR A SUBSIDIARY OF A FINANCIAL INSTITUTION? IF YES, PROVIDETHE FOLLOWING: a) NAME OF INSTITUTION; b) TYPE OF INSTITUTION (i.e. national bank, state chartered bank, bank holding company, etc.): c) IF SUBSIDIARY OR AFFILIATE, EXPLAIN

RELATIONSHIP TO FINANCIAL INSTITUTION: AND d) IF YOU ARE AN OFFICER OR EMPLOYEE OF A FINANCIAL INSTITUTIO9N AND THE FINANCIAL INSTITUTION IS NOT LICENSED, PROVIDE NOTARIZED AFFIDAVIT STATING YOU ARE NOT SELLING INSURANCE ON BEHALF OF THE FINANCIAL INSTITIUTION.

5. IF YOU ARE NOW OR HAVE EVER BEEN ENGAGED IN ANY PHASE OF THE INSURANCE BUSINESS, IS YOUR ACCOUNT WITH ANY COMPANY, AGENT OR INSURED NOW DELINQUENT OR IN DISPUTE? (IF YES, PROVIDE A FULL EXPLANATION ON A SEPARATE SHEET OF PAPER.)

6. ARE YOU FAMILIAR WITH AND DO YOU AGREE TO ABIDE BY ALL THE LAWS AND REGULATIONS PERTAINING TO THE BUSINESS OF INSURANCE IN THE COMMONWEALTH OF PENNSYLVANIA?

7. ARE YOU THE SUBJECT OF AN ORDER ISSUED BY THE COURT OR DEPARTMENT OF PUBLIC WELFARE UNDER 23 Pa.C.S.A. §4355 (DENIAL OR SUSPENSION OF LICENSES) RELATING TO DOMESTIC REALTIONS, FAILURE TO PAY CHILD SUPPORT, ETC?

LIST IN CHRONOLOGICAL ORDER YOUR CURRENT AND PREVIOUS RECORD OF EMPLOYMENT OR EDUCATION COVERING AT LEAST 2 YEARS PRECEDING THE DATE OF APPLICATION

CURRENT EMPLOYER

Name Address From To Occupation PREVIOUS EMPLOYER

(IF APPLICABLE) Name Address From To Occupation

I DO HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS AND INFORMATION ARE TRUE AND CORRECT AND THAT ANY LICENSE ISSUED IN CONSEQUENCE HEREOF SHALL BE CONTINGENT UPON THE TRUTH OF THESE STATEMENTS.

FURTHERMORE, I CONFIRM THAT I UNDERSTAND FULLY THE INSURANCE LAWS AND REGULATIONS OF PENNSYLVANIA REGARDING BROKER ACTIVITIES.

NOTE: FALSE STATEMENTS MAY RESULT IN CRIMINAL PENALTIES, APPLICATION DENIAL, ADMINISTRATIVE ENFORCEMENT ACTION OR ALL OF THE AFOREMENTIONED.

SUBSCRIBED AND SWORN TO BEFORE ME THIS ___________Day of _____________Year__________

Applicant Signature ____________________________________________

Notary Public (SEAL)

____________________________________________ Applicant Name (Printed or Typed) Commission Expires

NOTE: APPLICATION EXECUTED MORE THAN 3 MONTHS PRIOR TO THE DATE OF FILING WITH THE DEPARTMENT WILL NOT BE ACCEPTED. INFORMATION PROVIDED BY THE APPLICANT IN COMPLETING THIS FORM MAY BE SUBJECT TO PUBLIC DISCLOSURE UNDER PA LAW.

PART VI BACKGROUND INFORMATION

PART VII EMPLOYMENT HISTORY

PART VIII APPLICANT’S CERTIFICATION

(6)