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California Department of Insurance
Background Information Change Disclosure Form California Insurance Code Sction 1729.2
300 Capitol Mall 16th floor Sacramento, CA 95814 Licensing Hotline: (800) 967-9331 www.insurance.ca.gov
LIC 2557B (Rev. 9/2022)
This form has been developed to assist you in making the required background change reporting requirements under the provisions of California Insurance Code section 1729.2 . Failure to comply may result in denial or revocation of your license and/or denial of your application for a license. Providing your social security number is mandatory.
* If this Background Change Disclosure is being submitted by an organization, "you"means the organization and any officer, director, partner, member, endorsee, 10% or greater shareholder, and controlling person (as defined in Insurance Code Section 1668.5[b]). The changes subject to this requirement include changes pertaining to any unlicensed officer, director, partner, member, or controlling person, or any other naturanl person named under the business entity license or application.
** "Crime" includes a felony, misdemeanor or a military offense. "Convicted" includes, but is not limited to, having been found guilty by a verdict of a judge or jury, having entered a plea of guilty or nolo contendere, having had any charge expunged, dismissed or plea withdrawn pursuant to Penal Code 1203.4, or having been given probation, a suspended sentence or a fine. You may exclude traffic citations and juvenile offenses tried in juvenile court. You must disclose misdemeanor and felony vehicle code convictions, including any driving under the influence (DUI) convictions.
Important information for licensee who are endorsees under Business Entity licenses or Applications: If the background change reported by you involves you and you are an endorsee on a business entity license, then you must also provide this background change notice to any officer, director, or partner listed ont hat business entity license within 30 days of learning of the background change (CIC 1729.2[b]).
I certify that I have also notified the business entity license holder for which I am named as an endorsee on of the background changes I have notied in boxes above.
Important information for business entity licensees or applicants: If the background change matter being reported by you involves any unlicensed officer, director, partner, member, endorsee, 10% or greater shareholder, or any controlling person (as defined in Insurance Code Section 1668.5(b)) of the organization, then an officer, director, partner, member, or controlling person, (as defined in 1668.5(b)) must also report the background change involving the unlicensed person.
I certify that I am an officer, director or controlling person of an organization and I am notifying the Commissioner that an unlicensed officer director, partner, member, endorsee, 10% or greater shareholder, or any other controlling person as defined in Insurance Code Section 1668.5 has had a change in background information as per CIC 1729.2). I have noted the background changes being reported in the boxes above.
Provide Name of Unlicensed Officer, Director, Partner, Member, Endorsee, 10% or Greater Shareholder, or any other Controlling person as defined in CIC 1668.5.
I certify or declare under penalty of perjury under the laws of the State of California that I have read the above disclosures and that was statement made therein is full, true and correct. I understand that any changes in background information (per CIC 1729.2) must be filed within 30 days or my license can be subjected to disciplinary action. I certify that other than the disclosures being made above, I have no other unreported changes in background information to report as required under CIC 1729.2.
Please allow seven to ten business days for processing of 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.