BED-1

State of California Department of Insurance
Corportate/Limited Liability Company/Partnership Disclosure

BED-1 (Rev. 1/2023)
California Insurance Code section 1656.1
Form used for change of Business Entity Officiers/Ownership

Please list all current officers and directors of the business entity, regardless of ownership percentage.

Ownership of 10% or more must be reported and the sum of all percentages listed must add up to 80% or more.
If an organization(s) holds a majority ownership of licensee, please submit a separate form LIC BED1 for that parent company/companies.
If there is a new or change in partner please complete Form LIC 421-4 Copartnership - Application for Registration.

To look up a license number, please visit the Department's Check A License webpage.

The Application ID number can be retrieved using the following link: Check License Application Status Service (CLASS) - Select Business Entity

Organization/Business Entity Name

Organization/Business Entity FEIN #

License Number/Application ID

Organization/Business Entity Structure Type Value is not selected

Organization/Business Entity Structure Type (if "Other" selected)

Submission Type Value is not selected

Add or Remove Officer or Licensee Value is not selected

Total % Ownership

Ownership Validation

Select Number of Officers Value is not selected

Officer 1

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

1O ITIN Spacer

1O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 2

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

2O ITIN Spacer

2O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 3

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

3O ITIN Spacer

3O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 4

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

4O ITIN Spacer

4O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 5

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

5O ITIN Spacer

5O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 6

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

6O ITIN Spacer

6O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 7

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

7O ITIN Spacer

7O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 8

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

8O ITIN Spacer

8O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 9

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

9O ITIN Spacer

9O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 10

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

10O ITIN Spacer

10O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 11

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

11O ITIN Spacer

11O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 12

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

12O ITIN Spacer

12O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 13

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

13O ITIN Spacer

13O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 14

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

14O ITIN Spacer

14O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 15

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

15O ITIN Spacer

15O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 16

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

16O ITIN Spacer

16O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 17

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

17O ITIN Spacer

17O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Officer 18

Enter Officer Information

Officer Title Value is not selected

Officer Title (if "Other" selected)

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

18O ITIN Spacer

18O ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Organization Disclosure

A unique BED-1 form will be created and required to fill out for each organization listed

Select Number of Organizations Value is not selected

Organization 1

Enter Organization Information

Title Value is not selected

Business Name

FEIN

Owner? Value is not selected

% Ownership

Business Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Organization 2

Enter Organization Information

Title Value is not selected

Business Name

FEIN

Owner? Value is not selected

% Ownership

Business Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Organization 3

Enter Organization Information

Title Value is not selected

Business Name

FEIN

Owner? Value is not selected

% Ownership

Business Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Partnership Disclosure

Select Number of Partners Value is not selected

Partner 1

Enter Partner Information

Position

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

1P ITIN Spacer

1P ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Partner 2

Enter Partner Information

Position

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

2P ITIN Spacer

2P ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

Partner 3

Enter Partner Information

Position

Last Name

First Name

Middle Name

Select an ID Value is not selected

Social Security #

Individual Taxpayer Identification Number

3P ITIN Spacer

3P ITIN Validation

ID #

% Ownership

Begin Date

End Date

Residential Address

Address Line One

Address Line Two

City

State/Province

Zip Code

Country Value is not selected

If new or change in partner please complete Form LIC 421-4 Copartnership - Application for Registration, located on our web site.

Organization/Business Entity Director

I have reviewed this Business Entity Disclosure form and to the best of my knowledge the information listed here meets the disclosure requirements to California Insurance Code section 1656.1 *

Link to Insurance Code Section

Authorizing Officer, Manager, Member, Or Partner's Signature

Authorizing Officer, Manager, Member, Or Partner Signature Date

Authorizing Officer, Manager, Member, Or Partner's Name

Authorizing Officer, Manager, Member, Or Partner's Title

Authorizing Officer, Manager, Member or Partner's Contact Email Address

Authorizing Officer, Manager, Member or Partner's Telephone

Authorizing Officer, Manager, Member or Partner's Telephone Extension

Organization/Business Entity Name

Organization/Business Entity FEIN #

License Number/Application ID

Additional Attachments, If Necessary

REGEX Email Validation

Please allow 10 business days for processing this request.

License Number/Application ID Number and Email must match what is on file at CDI. Please click Back and correct on first tab.

Parent Entity Name

Email Validation

Org 1 Address Formula

Org 2 Address Formula

Org 3 Address Formula

1Address

2Address

3Address

4Address

5Address

6Address

7Address

8Address

9Address

10Address

11Address

12Address

13Address

14Address

15Address

16Address

17Address

18Address

19Address

20Address

21Address

1Name

2Name

3Name

4Name

5Name

6Name

7Name

8Name

9Name

10Name

11Name

12Name

13Name

14Name

15Name

16Name

17Name

18Name

19Name

20Name

21Name

1Title

2Title

3Title

4Title

5Title

6Title

7Title

8Title

9Title

10Title

11Title

12Title

13Title

14Title

15Title

16Title

17Title

18Title

1SSN

2SSN

3SSN

4SSN

5SSN

6SSN

7SSN

8SSN

9SSN

10SSN

11SSN

12SSN

13SSN

14SSN

15SSN

16SSN

17SSN

18SSN

19SSN

20SSN

21SSN

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BED-1

Officer 1

Officer 2

Officer 3

Officer 4

Officer 5

Officer 6

Officer 7

Officer 8

Officer 9

Officer 10

Officer 11

Officer 12

Officer 13

Officer 14

Officer 15

Officer 16

Officer 17

Officer 18

Organization 1

Organization 2

Organization 3

Partner 1

Partner 2

Partner 3

Organization/Business Entity Director