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CA Department of Insurance

Background Disclosure Form

Insurance Producer Licensing and Education Provider Laws AB 2557 (Koretz, Chapter 279, Statutes of 2004) that took Effect January 1, 2005

Background Information Change Disclosure Form and Instructions

The Background Information Disclosure form LIC 2557B gathers information as required by California Insurance Code Section 1729.2 to assist licensees and applicants to make required background change disclosures to the Commissioner subsequent to filing an application for a license or after having a license issued.

California Insurance Code Section 1729.2:

A. Effective January 1, 2005, California Insurance Code Section 1729.2 requires an applicant or licensee to notify the commissioner in writing within 30 days of the date the applicant or licensee learns of a change in background information.  

B. The law further requires that a business entity licensee, upon learning of a change in background information pertaining to any unlicensed person listed on its business entity license or application thereof, shall notify the commissioner of that change. The changes subject to this requirement include changes pertaining to any unlicensed officer, director, partner, member, or controlling person, or any other natural person named under the business entity license or application.

C.  Licensees who are named as endorsees under a business entity license must also report any change in background information as defined in CIC 1729.2(2) to any officer, director, partner, or controlling person as defined in CIC 1668.5(b) of the business entity license.

The law covers the following persons, licensees, entities and applicants:

Section 1729.2(1) of the California Insurance Code defines "license" to include all types of licenses issued by the commissioner pursuant to Chapter 5 (commencing with Section 1621), Chapter 5A (commencing with Section 1759), Chapter 6.5 (commencing with Section 1781.1), Chapter 7 (commencing with Section 1800) and Chapter 8 (commencing with Section 1831) of Part 2 of Division 1, Chapter 4 (commencing with Section 12280) of Part 5 of Division 2, and Chapter 1 (commencing with Section 14000) and Chapter 2 (Commencing with Section 15000) of Division 5.

Background information to be reported within 30 days includes any of the following:

  • A misdemeanor or felony conviction;
  • A filing of felony criminal charges in state or federal court;
  • An Administrative action regarding a professional or occupational license;
  • Discharge or attempt to discharge in a personal or organizational bankruptcy proceeding, an obligation regarding any insurance premiums or fiduciary funds owed to any company, including a managing general agent or premium finance company; and
  • Any admission, or judicial finding or determination, of fraud, misappropriation or conversion of funds, misrepresentation, or breach of fiduciary duty.

Instructions:

If you are a Business Entity Licensee (including an Officer, Director, Partner, or Member named under a Business Entity License) and/or if you are an Endorsee Under a Business Entity License complete form LIC 2557B Sections A, B, C, E.

If you are an Individual licensee or applicant complete form LIC 2557B Sections, A, B, E.  

If you are an Officer, Director, Partner or Controlling Person of a Business Entity license reporting a background change involving an unlicensed officer , director, Controlling Person or member complete form LIC 2557B Sections A, B, D, E.

If you need additional space to provide the necessary information, please use Supplemental Disclosure, form LIC 2557 Supplemental.

Mail completed form, along with any supplemental statements and any attachments and/or certified court documents as required to:

California Department of Insurance
Licensing Background Bureau
320 Capitol Mall
Sacramento, CA 95814-4309


Questions concerning the Background Change Reporting Requirements may be directed to:

California Department of Insurance
Licensing Background Bureau
320 Capitol Mall
Sacramento, CA 95814-4309
Telephone (916) 492-3650

Form LIC 2557A (Rev. 10/12)

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