Premium Finance Form LHL105 - PF1C

By Julie Morris,2014-08-08 06:34
9 views 0
Premium Finance Form LHL105 - PF1C

    Texas Department of Insurance

    Financial, TPA/Premium Finance, Mail Code 305-TPA/PF

    333 Guadalupe • P. O. Box 149104, Austin, Texas 78714-9104 512-322-3579 • 512-322-5026 fax •


    This application must be completed and returned to this Department no later than

    DECEMBER 31, 2008 regardless of whether or not you are renewing the license for 2009.

     [Manager] November 20, 2008


     [PhysicalAddress] License #: [LicenseNumber]

     [PhysicalCity], [PhysicalST] [PhysicalZip] EID: [EID] ([PorB])

     (P-EID: [ParentEID])



    By Mail: By Overnight Delivery:

    P.O. BOX 149104 333 GUADALUPE

    AUSTIN, TEXAS 78714-9104 AUSTIN, TEXAS 78701

    IF RENEWING: Return this completed Form PF1C, $200 Renewal Fee; and if licensee is a corporation, a current Franchise Tax Certificate of Good Standing ( or Letter of Exemption issued by the Texas Comptroller of Public Accounts.

    IF NOT RENEWING: Return this completed Form PF1C and 2007 Certificate of License. (However if you have open loans, you must keep your license current.)

    Renewals POST MARKED after DECEMBER 31, 2008 but less than 90 days late, require payment of the $200 Renewal Fee and a $100 Penalty Fee before business may be resumed. Renewals received more than 90 days late but less than two years may be renewed by paying: all unpaid renewal fees and an additional fee equal to the original license fee;

    please contact our office for the exact fee. A license expired for two years or more MAY NOT be renewed.

Please answer all of the following questions: Yes No

    1. Do you wish to renew your Premium Finance License for 2009?

    2. Are you currently making premium loans?

    3. Do you have any open loans?

    4. If not currently active, do you intend to commence business in the near future?

     If yes, on what date? ______________________________________ 5. Do you understand that whether you renew or non-renew your Premium Finance

     license for 2009, you are still responsible for submission of a 2008 Annual Operations Report

    and Annual Assessment Fee, due April 1, 2009?

    6. Do you consider yourself an independent Insurance Premium Finance Company?

     (If yes, then skip question 7.)

    7. Are you affiliated or have common ownership with any of the following?

     If "yes", check below all that apply and explain on the back of this application:

     Insurance Agent Managing General Agent Bank, Savings & Loan and/or Credit Union

     Insurer Another Premium Finance Company Regulated Loan Company

    8. Does the licensee at all times maintain net assets for use in the insurance premium

     finance business of not less than $25,000?

     (Net assets are defined as the total value of assets available for use in the business less liabilities.)

    FIN163 Rev. 12/2008 Page 1 of 2

    I hereby certify that the information shown and the answers given herein are true and correct.

     Signature _______________________________________________ Name ___________________________________________________ Date ___________________________________________________ Title ____________________________________________________

    9. If information in the shaded areas below is incorrect, report corrections on the line below and submit appropriate

    documentation and forms (ref. the website noted at the bottom for forms and instructions): Company Name: [CompanyName]

    Company Name:

    Doing Business As Name (DBA): [DBA Name]


    FEIN: [FEIN] Licensed Date: [LicenseDate]

    FEIN: Licensed Date:



    Mailing Address: [MailAddress], [MailCity], [MailST] [MailZip]

    Mailing Address:

    Physical Address: [PhysicalAddress], [PhysicalCity], [PhysicalST] [PhysicalZip]

    Physical Address:

    Home Office (City, State): Manager: [Manager]

    Home Office (City, State): Manager:

    Website Address: [WebAddress]

    Website Address:

    Email Address: [EmailAddress]

    Email Address:

    Office Phone: [OfficePhone] Fax Phone: [FaxPhone] Toll Free: [TollFreePhone]

    Office Phone: Fax Phone: Toll Free:

    10. Are books and records located at a location different from the physical address listed above? If yes, where:


11. Do you use the services of a premium finance servicing company or another licensed premium finance company to

    process premium finance agreements produced under your company name? If yes, then list the name, address, and

    phone number of the servicing company (if necessary, attached additional page): Name: __________________________________________________________ Phone: ________________________ Address: _________________________________________________________________________________________

Additional information required by question 7 or any other explanation/comment:




    Reference the following website for Texas premium finance licensing requirements, regulations, and forms:

    If you have questions or require assistance, please send an email to

    or call (512)322-3579.

    FIN163 Rev. 12/2008 Page 2 of 2

Report this document

For any questions or suggestions please email