Important Note: All documentation requested in the following questionnaire must be received by Kennedy before final processing of your application and submission to the state(s). This includes such things as license copies as specified, copies of any applicable regulatory sanctions, court or arrest records and all other explanations to any "Yes" answers to the questions. Omitting or withholding of this information is often cause for license suspension, revocation or even criminal prosecution.

1) FEIN (IRS tax id required):
2) Firm Full Name:
3) IF DBA in resident state, do you prefer DBA in nonresident state? yes No
4) If yes, give full DBA name:
5) Type of Business: Corporation | LLC | LLP |
General Partnership | Limited Partnership | Sole Proprietorship
7) Physical Street:
8) City:
9) State:   10) Zip:   10a) County:
11) Postal Street (if different):
12) City:
13) State: 14) Zip:   15) County:
16) 800 Phone:
17) Phone:    18) Fax:
19) E-mail (required):
Legal Data
20) State of formation/Domicile:
21) Date of Incorporation/Formation:  Month  Day   Year
22) Fiscal Year End:  Month  Day
23) Duration of Firm: Perpetual  Number of years
Stock Information
24) Class:   25)  Series:
26) Number Authorized:   27) Number Issued:

28) Par value:
29) Stated Capital: (Usually, total issued shares x par value per share)


If applicant firm is owned by another entity.

30) Name of entity:
31) Address:
32) City:
33) State:     34) Zip:
35) County:
36) FEIN:   37) Ownership %:
List all officers, directors, stockholders, members and/or partners.
Send additional sheets if necessary.
38) Full Name:
39) Title: 40) Ownership %:

41) Resident Street:
42) City:
43) State:   44) zip:

45) SSN:   46) Birth Date: mm/dd/yyyy
47) Full Name:
48) Title: 49) Ownership %:

50) Resident Street:
51) City:
52) State:   53) zip:

54) SSN:   55) Birth Date: mm/dd/yyyy
56) Full Name:
57) Title: 58) Ownership %:

59) Resident Street:
60) City:
61) State:  62) zip:

63) SSN:   64) Birth Date: mm/dd/yyyy
65) Full Name:
66) Title: 67) Ownership %:

68) Resident Street:
69) City:
70) State:   71) zip:

72) SSN:  73)  Birth Date: mm/dd/yyyy
74) Full Name:
75) Title: 76) Ownership %:

77) Resident Street:
78) City:
79) State:  80) zip:

81) SSN:  82) Birth Date: mm/dd/yyyy
History and Qualification Information
83) .   Has the firm, or any of it's owners, officers, directors, partners, or members individually or through connection with any other entity ever: 

a.   Been an officer or employee of a financial institution or a subsidiary of a financial institution?

Yes No

b.   Entered a plea of Nolo Contendere to a criminal action?

Yes No

c.   Been fined by any state or government regulatory agency or authority?

Yes No

d.   Been charged with, arrested for or convicted of a misdemeanor, felony or military offense?

Yes No

e.   Compromised liabilities with creditors, been insolvent or adjudged bankrupt?

Yes No

f.   Been indicted, convicted, enjoined, restrained by a court or regulatory agency for violation of any Federal or State law relating to insurance or securities?

Yes No

g.   Had any professional license (other than insurance) held or applied for revoked, suspended, refused or the renewal thereof denied by a regulatory body of any state, district or territory?

Yes No

h.   Been notified of any delinquent tax obligation that is not subject to a repayment agreement by any jurisdiction to which you are applying?

Yes No

i.   Been found liable in any arbitration proceedings or lawsuit(s) involving allegations of conversion or misappropriation of funds, misrepresentation, breach of fiduciary duty or fraud?

Yes No
 (If the answer was "Yes" to any of the above questions, a full and complete explanation must be provided on a separate sheet)
84) .   Does the firm have branch offices? If yes, send list of addresses and phone numbers for each branch.
Yes No
85).   Has the firm ever had an insurance license denied, suspended, revoked, restricted, canceled, terminated, censured, placed on probation and/or have any regulatory complaints ever been made against it? If yes, send complete explanation
Yes No
86).   Has/is the firm engaged in any other business or activity other than insurance? If yes, give nature of business or activity and time percentage.  
Yes No
87) .   Has firm been refused issuance of a Surety or Fidelity Bond, had a bond canceled for cause, or has a surety ever been called upon to pay a claim on the firm's behalf? If yes, send complete details.
Yes No
88). Has firm ever had an agency contract canceled or an other business relationship with an insurance company terminated for any alleged misconduct or for any reason? If yes, send complete details (dates, companies, reason canceled).  
Yes No
89).   Is the firm connected IN ANY WAY with any real estate agency, lending institution or automobile dealer? If yes, state name and address and connection therewith.  If lending institution is FDIC insured, please indicate.  
Yes No
90) .   Is the firm currently selling insurance over the internet? If yes, identify the following:
Yes No
Name of Website:  
Server Location:  
Carrier information
Primary Property & Casualty Carrier
91) Name of Carrier:
(Actual full name of carrier, Not Group)
92) Address:
93) City:
94) State:    95)  Zip:
96) Contact name: (preferably licensing dept.)
97) Phone:   98) 800:
99) E-mail:
100) Fax:
Primary Life, Accident & Health, L&D Carrier

101) Name of Carrier:
(Actual full name of carrier, Not Group)
102) Address:
103) City:
104) State:    105) Zip:
106) Contact name: (preferably licensing dept.)
107) Phone:  108)  800:
109) E-mail:
110) Fax:

Current Resident Licenses (please send copies)

License number(s)
Initial issue date(s)
Expiration date

State licenses being applied for