Criminal History Disclosure Form
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For misdemeanor history complete Sections I, II and IX. For
felonies, please complete the entire form.
Remember to keep a copy of the completed form for your records.
Responses on the form must be typed.
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| Criminal History Disclosure Form with Information and Instructions |
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| Criminal History Disclosure Form |
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FAQs
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PLEASE NOTE: The Alabama Department of Insurance cannot give
legal advice. If you think you need legal advice, you should contact an
attorney. The Alabama State Bar offers a Lawyer Referral Service. You can find
more information on the Lawyer Referral Service at the Alabama State Bar’s
website -- www.alabar.org.
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| What is the purpose of the Criminal History
Disclosure Form? |
| The Alabama Commissioner of Insurance may
consider an applicant’s criminal history in deciding whether to grant an
application for a license or, if an individual already holds a license, whether
to renew, suspend, or revoke that license.
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| Under 18 U.S.C. § 1033, it is a Federal criminal
offense for an individual who has been convicted of an offense described in
that statute or of a felony involving dishonesty or breach of trust to engage
in the business of insurance without the written consent of an insurance
regulatory official authorized to regulate insurers. This Federal statute
applies to licensed and unlicensed positions in the business of insurance.
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| This form is intended to obtain detailed
information about an individual’s criminal history sufficient to permit the
Commissioner to decide whether to grant, renew, or allow retention of a
license; to decide whether written consent under 18 U.S.C. § 1033 is required;
and to decide whether to grant written consent for purposes of 18 U.S.C. §
1033, if required.
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You should review Insurance Department Regulation 482-1-146,
available in the Legal section at www.aldoi.gov,
for further information.
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| What types of convictions can be considered? |
| Under Alabama law,
conviction of any felony can be a ground for denial, non-renewal, suspension,
or revocation of a license. |
| The consent requirement of 18 U.S.C. § 1033
relates to a conviction of a specific insurance-related crime defined in § 1033
or of a felony involving dishonesty or breach of trust. |
| What is the difference between a felony and a
misdemeanor? |
| In general, a felony is an offense for which a
sentence of incarceration for more than one year can be imposed. A misdemeanor,
on the other hand, is an offense for which a sentence of incarceration may not
exceed one year. Since the definition of a felony may vary from state to state,
the Department will defer to how the jurisdiction where the offense was
committed classifies the offense. |
| What is a § 1033 consent and when is one
required? |
| 18 U.S.C. § 1033 is a Federal statute that makes
certain acts within the business of insurance Federal criminal offenses. The
statute also provides that it is a Federal criminal offense for a person who
has been convicted of a crime defined in § 1033 or of a felony involving
dishonesty or breach of trust to engage in the business of insurance unless
that person has written consent of the appropriate state regulatory official.
In Alabama, that official is the Commissioner of Insurance. |
| The consent requirement applies to licensed
positions within the business of insurance. It can also apply to employment or
contract positions in the business of insurance that do not require a license. |
| A license is not equivalent to a § 1033 consent.
A § 1033 consent is separate from a license. |
| If I am applying for a non-resident license,
must I have a § 1033 consent from my resident licensing state? |
| Yes. If consent is required under § 1033, a
non-resident must have received a written consent from the proper insurance
regulatory official in his/her resident licensing state – or that official’s
written determination that a § 1033 consent is not required for a particular
felony. The consent or determination of non-applicability must relate to the
activities in the business of insurance for which the non-resident is seeking
an Alabama license. Alabama will accept the resident state’s § 1033 consent (or
determination § 1033 does not apply) if it is the policy of the resident state
to give like validity to such consents or non-applicability determinations by
Alabama to Alabama residents seeking non-resident licenses in that state.
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| What is considered a felony involving
“dishonesty or a breach of trust” for § 1033 purposes? |
| This will be determined by the Department based
upon the circumstances of a particular felony conviction. In general, any
felony which, under the applicable laws of the jurisdiction where committed,
includes one or more elements of deceit, untruthfulness, or falsification will
be deemed a felony involving “dishonesty” for purposes of applying the § 1033
consent process. Such crimes can include, but are not limited to, any offense
constituting or involving perjury, bribery, forgery, counterfeiting, false or
misleading oral or written statements, deception, fraud, schemes or artifices
to deceive or defraud, material misrepresentations and the failure to disclose
material facts. In general, any felony which, factually or as an element of the
offense, involves breach of a fiduciary-type duty imposed by applicable laws of
the jurisdiction where committed will be deemed to be a felony involving a
“breach of trust” for purposes of applying the § 1033 consent process.
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| Who must complete the Criminal History
Disclosure Form? |
| This form (or relevant parts of it) must be
completed by any individual: (1) who first discloses in a license application
that he/she has been charged with or convicted of a criminal offense; (2) who
discloses a felony arrest, indictment, or conviction as required by Insurance
Department Regulation 482-1-054; (3) about whom the Department has discovered
the existence of undisclosed prior charges or convictions for a criminal
offense; or (4) who requests written consent under 18 U.S.C. § 1033.
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| What do I need to do?
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| Carefully read through these instructions and
the form to see what parts apply to you and what information you will need to
send or gather. Depending on your individual circumstances, some parts of the
form may not apply to you. If a question does not apply, you may leave
it blank or type in “N/A.”
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| If you only have prior misdemeanor violations
and have NOT been convicted of a felony, you need to complete only Sections I,
II, and the signature part in Section IX; and you do NOT need to attach
photographs. |
| Answer the questions that apply to you fully,
accurately and truthfully. Please TYPE your responses. You should attach
additional pages if necessary. Misstatements in or omissions from the form may
have serious consequences, including criminal prosecution.
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| Provide all the documentation requested. Copies
of documentation obtained from a court or government agency must be certified
by that court or agency. You must substantiate any claimed inability to get
certified copies of court or agency records.
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| Be sure to date and sign the form and have your
signature notarized.
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| The form must be complete with all necessary
documentation attached when it is submitted to the Department. The Department
will not process an incomplete form. Failure to submit all the required
information will delay any final action.
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| Keep a copy of the form and documentation for
your records. The original completed form and all documentation should be sent
to: |
Alabama Department of Insurance
Attn: Legal Division
P.O. Box 303351
Montgomery, Alabama 36130-3351
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| When should I return the completed form? |
| You should return the completed form and all
applicable documentation as soon as possible but within any time period stated
in any official communication from the Department. Be sure to keep a copy of
the completed form for your records. You may be requested to submit additional
written information and/or to be interviewed. If so, you should comply with the
time periods set forth in the request. |
| If you have a license application pending, that
application will not be acted upon until after the completed form and
documentation and requested additional information, if any, have been received
and reviewed by the Alabama Department of Insurance and any interview, if
requested, has been completed. If you have not returned the completed form and
documentation the time stated in an official communication from the Department
or if you do not properly respond to a request for additional information or an
interview, your license application may be denied and you will be required to
reapply for the license.
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| What if I need to make a change on the form
due to a change in circumstances? |
| A written amendment to the form must be filed
immediately upon the occurrence of any event which would change any answer on
the application. If you fail to file a timely amendment, it could result in
denial or withdrawal of approval or written consent. |
| What is done with the Criminal History
Disclosure Form? |
| A Review Committee of the Department of
Insurance will review the completed form and documentation, any supplemental
information, and interview results, and make a recommendation to the
Commissioner about what action should be taken. The Commissioner is not bound
by the recommendation.
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| The form will be treated as confidential by the
Department and will not be deemed a public record.
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| Information disclosed in the form may be the
basis for further administrative action by the Department.
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| How long does the process take?
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| Once the information-gathering process is
complete, the Department will make reasonable efforts to have a final
disposition from the Commissioner within twenty (20) days. The actual time
could be longer.
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| If the Department requests additional
information and/or a personal or telephone interview, the review and decision
process will not continue until, and the twenty (20) day target disposition
time will run from, the later to occur of receipt of the requested information
or completion of the interview.
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| What can I do if my application or request
for consent is denied? |
| If you disagree with a decision to deny a
license application and/or a request for an 18 U.S.C. § 1033 consent, you may
request a hearing before the Commissioner or his/her designee. If that hearing
is requested and conducted, and you disagree with the result, you may seek
review by a court. The notification you receive will generally describe these
options.
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| What if I have further questions? |
| In case of questions, you may contact the
Alabama Department of Insurance Legal Division at 334-241-4117.
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