Ohio Department of Insurance
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Pre-Application Determination
Applicant Information
First Name
Last Name
Date of birth
Email Address
Address Line1
Address Line2
City
State
Select State
AK
AL
AR
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NOT SPECIFIED
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip Code
Telephone number
License type for which you or affiliated entity seeks a pre-application determination
Select License Type
Limited Lines
Limited Lines Portable Electronics
Limited Lines Self-Service Storage
Major Lines
Managing General Agent
Public Insurance Adjuster
Public Insurance Adjuster Agent
Reinsurance Intermediary Broker
Reinsurance Intermediary Manager
Surety Bail Bond
Surplus Lines
Third Party Administrator
Title
Title Insurance Marketing Rep
Viatical Settlement Broker
Change
Uppercase Only
Criminal Conviction Information
At least one conviction record required.
Attestation required to Submit Form
Add New Criminal Conviction
Conviction Records
Offense Name
Conviction Felony
Applicable statutory citations
Action
No Convictions to display
Specific name of criminal offense(s)
Applicable statutory citations
Is the Conviction a Felony
Yes
No
Certificates of Qualification for Employment and Certificates of Achievement and Employability
A disqualification may be overcome if an individual holds a certificate of qualification for employment issued under R.C. 2953.25 or a certificate of achievement and employability issued under R.C. 2961.22. For more information on these certificates, please visit
https://drc.ohio.gov/cqe
.
Are you the recipient of a certificate of qualification for employment issued under R.C. 2953.25 or a certificate of achievement and employability issued under R.C. 2961.22?
Yes
No
Have you been convicted of, or pleaded guilty to, a felony committed subsequent to the issuance of the certificate?
Yes
No
Attestation
I hereby certify that all of the information submitted in this form is true and complete. I acknowledge that the Ohio Department of Insurance is not bound by its determination if, upon further investigation, it finds that my criminal convictions differ from what is included in this request form. I acknowledge that this form is not an application for licensure. I also acknowledge that this pre-application determination does not guarantee the issuance of a license.
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