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Live Scan Service Request (Company Officers Directors Others) Form. This is a California form and can be use in Department Of Insurance Statewide.
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Tags: Live Scan Service Request (Company Officers Directors Others), LIC 051-CIU, California Statewide, Department Of Insurance
State of California LIC 051-CIU (Rev. 5/12) Attention Live Scan Service Providers, Company Officers, Directors, and Others Department of Insurance Live Scan Service Request (Company Officers, Directors, and Others) The California Department of Justice (DOJ) and Federal Bureau of Investigation's (FBI) processing fees are to be paid by the license applicant or the officer's/director's company. Be prepared to pay fees at the time your fingerprints are taken at the live scan service provider site or submitted to Accurate Biometrics. Please prepare three copies of this form and distribute as follows: 1) First Copy (Original) to the Live Scan Provider; 2) Second Copy to Requesting Agency; 3) Third Copy to the Person being fingerprinted. *If the applicant completes a 1033 Consent Waiver (18 U.S.C. §1033), that applicant is to make a Fourth Copy of this form and send it to the California Department of Insurance. Part 1 Personal Information Please type information below Applicant Name (Last, First, and Middle) Former Name(s)/AKA's (Last, First) Date of Birth (MM/DD/YYYY) Eye Color Social Security Number Gender Male Female Height Weight Place of Birth Hair Color Driver's License Number Daytime Telephone Number ( ) Residence Address (Street/PO Box, City, State, Zip Code) Department and Live Scan Vendor Only Part 2 To be completed by Contributing Agency Agency ORI Number Agency Address OCA Number: A0042 California Department of Insurance Licensing Compliance and Company Investigations Bureau 320 Capitol Mall Sacramento, Ca 95814-4309 Job Title: Insurance 04605 Level of Service: California Department of Justice and Federal Bureau of Investigation Part 3 To be completed by Live Scan Vendor Live Scan Transaction Completed by: Date Completed Transmitting Agency (Name of Operator) 2000 Application Type (e.g. type of search) License Certificate or Permit Mail Code, (five-digit code assigned by DOJ) : Terminal ID: Amount Collected (for rolling fee) Amount Collected (For DOJ/FBI Processing) ATI Number Part 4 To be completed by Live Scan for Fingerprint Resubmission Level of Service Requested for Resubmission Original ATI Number California Department of Justice Federal Bureau of Investigation American LegalNet, Inc. www.FormsWorkFlow.com Original Live Scan Operator, Second Copy Requesting Agency, Third copy Applicant LIC-051-CIU (Rev. 05/12) Reverse Side Instructions for Insurance Company Officers and Directors Residents Submitting Live Scan Form Step 1: Insurer/Company Fingerprint Requirement: All company officers, directors, key managerial personnel, and individuals with a 10 percent or more beneficial ownership in the applicant and applicant's controlling parent will need to be fingerprinted. Fingerprints must be taken at either a live scan vendor or by a local law enforcement agency on a fingerprint card that is to be sent to Accurate Biometrics. Step 2: Completion of Live Scan Form: The following information must be entered in Part 1 of the form by the applicant: Your printed name and former names (if any); Date of birth, gender, height, weight, eye color, hair color, place of birth, social security number (SSN), driver's license number, and residence address. The Contributing Agency will complete Part 2 of this form. The electronic fingerprint service provider will complete Part 3. Step3: Fingerprint Services: Live Scan Fingerprint Services available in California: The California Department of Justice (DOJ) maintains a listing of Live Scan fingerprinting services available to the public. The DOJ list is broken down by county. Fees vary from location to location. Applicants are encouraged to contact the Live Scan provider in advance to verify their current operating hours, fees, etc. This list is available at the following website: http://ag.ca.gov/fingerprints/publications/contact.php For your convenience, CDI's contracted vendor, Accurate Biometrics will have staff available at the CDI's examination sites to complete the fingerprint impression requirement. Step 4: Fees: The following fees must be paid by the applicant: Processing and Service Fee: The cost of the Accurate Biometrics' live scan service is $58.30. The $58.30 processing fee covers the following services: Federal Bureau of Investigation fingerprint check is $17, State of California Department of Justice fingerprint check is $32, and Accurate Biometrics' rolling fee is $9.30. The applicant may pay with all major credit cards -- VISA, MasterCard, American Express and Discover Card. In addition, a money order, cashier's check, company check or personal check in the amount of $58.30 made payable to "Accurate Biometrics" will also be accepted. Step 5: Submission of Fingerprint Form: Make three copies of the form. Please take the original completed Live Scan form to the live scan provider for processing. The second copy is to be mailed to the California Department of Insurance, Licensing Compliance and Company Investigations Bureau, 320 Capitol Mall, Sacramento, CA 95814-4309. The third copy is to be maintained for your records. Non-residents Submitting Manual Fingerprint Card(s) Step 1: Insurer/Company Fingerprint Requirement: All company officers, directors, key managerial personnel, and individuals with a 10 percent or more beneficial ownership, and the applicant and applicant's controlling parent will need to be fingerprinted. Fingerprints must be taken at either a live scan vendor or by a local law enforcement agency on a fingerprint card that is to be sent to Accurate Biometrics. Step 2: Mail Fingerprint Card, Live Scan Form & Fees Directly to Accurate Biometrics: Keep a copy of the Live Scan form your records. Mail original copy of the completed Live Scan form along with your fingerprint card submission and check for $58.30 made payable to Accurate Biometrics to the following address: Accurate Biometrics, 8680 Greenback Lane, Suite 200, Orangevale, CA 95662. Step 3: Fees: The following fees must be paid by the non-resident applicant: Processing Fee: The cost of the Accurate Biometrics' live scan service is $58.30. The $58.30 processing fee covers the following services: Federal Bureau of Investigation fingerprint check is $17, State of California Department of Justice fingerprint check is $32, and Accurate Biometrics rolling fee is $9.30. The applicant may pay by credit card using Accurate Biometrics' credit card payment form or by check or money order made payable to Accurate Biometrics. Service Fee: A separate fee w