Fillable State of California Department of Insurance Live Scan (California)

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State of California Department of Insurance Live Scan (California)

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State of California Department of Insurance
Live Scan Service Request (Applicant)
LIC 442-39A (Rev. 01/2020)
Attention:
Live Scan Service Providers, Resident and Nonresident License Applicants, and
1033 Consent Waiver (18 U.S.C. §1033) Applicants
The California Department of Justice (DOJ) and Federal Bureau of Investigation’s (FBI) processing fees are to be paid by the license applicant.
Be prepared to pay the fees at the time your fingerprints are taken at the license scan service provider site.
The applicant is to make two copies of this form and distribute as follows:
1) First Copy (Original) to the Live Scan Provider;
2) Second Copy to the Applicant.
If the applicant completes a 1033 Consent Waiver (18 U.S.C. §1033), that applicant is to make a Third Copy of this form and send it to the
California Department of Insurance.
Part 1
Applicant’s’ Personal Information
Please type or print clearly the information below
Applicant Name (Last, First, and Middle)
Former Name/AKA’s (Last, First)
Date of Birth (MM/DD/YYYY)
Gender □ Male □ Female
Height
Weight
Eye Color
Hair Color
Place of Birth
Social Security Number
Driver’s License Number
Daytime Telephone Number
(
)
Residence Address (Street/PO Box, City, State, Zip Code)
Department and Live Scan Vendor ONLY
To be completed by Contributing Agency
Agency ORI Number
A0042
Agency Address
California Department of Insurance
Producer Licensing
320 Capitol Mall, Sacramento, CA 95814
OCA Number:
1000
Application Type: (e.g. type of search)
License Certificate or Permit
Job Title:
Insurance
Mail Code:
(five-digit code assigned by DOJ)
04605
Level of Service: California Department of Justice and Federal Bureau of Investigation
To be completed by Live Scan Transaction
Live Scan Transaction Completed by: (Name of
operator)
Date Completed
Transmitting Agency
Terminal ID
Amount Collected (For rolling fee)
Amount Collected:
(For DOJ/FBI Processing)
ATI Number
To be completed by Live Scan for Fingerprint Resubmission
Original ATI Number
Level of Service Requested for Resubmission
□ California Department of Justice □ Federal Bureau of Investigation
Original - Live Scan operator, Second Copy - Requesting Agency, Third copy – Applicant
H H
LIC 442-39A (Rev. 04/2013) – Page 2
Resident Producer Licensing Applicant Instructions
Step 1: 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. The live scan vendor will complete Part 3 and, if necessary, Part 4 of this form.
Step 2: Producer Fingerprint Requirement: One set of classifiable electronic fingerprints is required for every California Department of Insurance (CDI)
applicant unless the applicant is currently licensed or held a CDI license which expired during the last 12 months.
Step 3: 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: At CDI’s examination site, the total processing fee for the fingerprint impressions taken by CDI’s contracted vendor is $59 which includes
the FBI processing fee of $17, DOJ processing fee of $32, and the CDI’s contractor’s rolling fee of $10 . The $59 fee is to be paid at CDI’s examination
site. 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 $59 made payable to "Accurate Biometrics” will also be accepted.
At PSI’s test center, the total processing fee for the fingerprint impressions taken by MorphoTrust USA is $68.95 which includes the FBI processing fee
of $17, DOJ processing fee of $32, and the rolling fee charged by PSI of $19.95. The $68.95 fee is to be paid at the PSI test center. They accept money
order, cashier’s check, company check (made payable to MorphoTrust USA), VISA and MasterCard. Personal checks and cash will not be accepted.
In addition, applicants using a DOJ authorized vendor on DOJ’s Live Scan Fingerprinting vendors list will need to pay a fingerprint fee that covers the FBI
processing fee of $17, DOJ processing fee of $32, and an additional "rolling fee" charged by the DOJ authorized vendor. The additional "rolling fee" will
vary depending on the vendor and is noted on DOJ's list of vendors. License applicants are encouraged to contact the Live Scan provider in advance to
verify their current operating hours, location, fees, and their acceptable method of payment (i.e. credit card, cash, ATM).
Step 5: Submission of Fingerprint Form: Please take this form to the live scan provider for processing.
Non-Resident Producer Licensing Applicant Instructions
Step 1: 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 and, if
necessary, Part 4 of this form.
Step 2: Mail Fingerprint Card, Live Scan Form & Fees Directly to Accurate Biometrics. Keep a copy of the Live Scan form for your records. Mail
original copy of the completed Live Scan form along with your fingerprint card submission and Accurate Biometrics’ credit card payment form or check
made payable to Accurate Biometrics to the following address: Accurate Biometrics, 12777 W Jefferson Blvd. - Building D, Suite 3111, Los Angeles, CA
90066.
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 $59. The 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
$10.
Service Fee: A separate fee will be charged for the service of taking the fingerprint impressions by a fingerprint technician or live scan fingerprints
by the live scan provider. That fee may vary depending on the fingerprint vendor or live scan provider you choose.
1033 Consent Waiver (18 U.S.C. §1033) Applicants
Step 1: Completion of Live Scan Form: Follow same instructions as indicated above for resident license applicants.
Step 2: Fingerprint Services: Follow same instructions as indicated above for resident license applicants.
Step 3: Submission of Fingerprints: Follow the same instructions as indicated above for resident license applicants, however, a third copy of the Live
Scan Form must be mailed to the California Department of Insurance, Producer Licensing Background Section, 320 Capitol Mall, Sacramento, CA
95814-4309. The second copy is to be maintained by the applicant for your records.
Step 4: Fees: Follow the same instructions as indicated above for resident license applicants.
aiometric.s
Live
Scan
Fingerprinting
&
Ident
i
ty
Se
Credit Card Payment Form
* Denotes Required Fields
(as it appears on credit card)
Applicant Name
* Name
Company Name (if applicable)
* Billing Address
Billing Address 2
* City
* State/Province
* Postal (ZIP) Code
* Country
* Credit Card #:
* Expiration Date (MM/YYYY)
* CVC
Code:
* Total
Amount To Be Billed To Credit Card: $59
* Card Holder Signature
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Completed 21 July 2020

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