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Request for Restriction Removal

California Department of Insurance

CALIFORNIA DEPARTMENT OF INSURANCE

Curriculum and Licensing Background Bureau - Licensing Background Section

300 Capitol Mall

Sacramento, California 95814

Licensing Hotline: (800) 967-9331

Please complete the Background Questionnaire and attach a written statement explaining why you are requesting restrictions to be removed.

1. Have you been convicted of a misdemeanor or military offense or had a judgement withheld or deferred which has not been previously reported to this insurance department or are you currently under investigation or charged with committing a misdemeanor or military offense? (For the purpose of this question you have been "convicted" if you were ever found guilty by verdict of a judge or jury; and/or ever entered a plea of guilty, nolo contendre or no contest. You must disclose all convictions, including driving related misdemeanors, even if the charges were later dismissed or expunged or your guilty plea was withdrawn pursuant to Penal Code Section 1203.4, or you were placed on probation, received a suspended sentence or just ordered to pay a fine.)

2. Have you been convicted of a felony or military offense or had a judgement withheld or deferred which has not been previously reported to this insurance department or are you currently under investigation or charged with committing a felony or military offense? (For the purpose of this question you have been "convicted" if you were ever found guilty by verdict of a judge or jury; and/or ever entered a plea of guilty, nolo contendre or no contest. You must disclose all convictions, even if the charges were later dismissed or expunged or your guilty plea was withdrawn pursuant to Penal Code Section 1203.4, or you were placed on probation, received a suspended sentence or just ordered to pay a fine.)

3. Have you been named or involved as a party in an administrative proceeding, including a FINRA sanction or arbitration proceeding regarding any professional or occupational license or registration, which has not been previously reported to the CA Department of Insurance? (“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, placed on probation, sanctioned or surrendering a license to resolve an administrative action. “Involved” also means being under investigation or named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. “Involved” also means having a license, or registration, application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of your actions in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company.)

Your email and license number were unable to be validated. Please double check you are using the email on file and there are no typos. You may still submit this request. Please email LICBackgrounds@insurance.ca.gov with any questions.