DEPARTMENT OF INSURANCE

PUBLIC PROTECTION
CABINET

DEPARTMENT OF INSURANCE

Affiliations

Name	Gossom III, Richard	DOIID	861096	NAIC NPN	17427272

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Denied	Resident	Agent	Personal Lines
Denied	Resident	Agent	Property
Denied	Resident	Agent	Casualty
Inactive	Resident	Agent	Life	12/2/2014	3/1/2017
Inactive	Resident	Agent	Health	12/12/2014	3/1/2017
* If a status Is Pending, Pending Replacement,Or the record displays Affidavit On File, click On them For more details.

Appointments with the following Insurers

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Assurity Life Insurance Company	301099	Agent - Health	2/8/2016	3/1/2017
Inactive	Assurity Life Insurance Company	301099	Agent - Life	2/8/2016	3/1/2017
Inactive	Northwestern Long Term Care Insurance Company	300135	Agent - Health	6/29/2015	3/1/2017
Inactive	Northwestern Mutual Life Insurance Company	300931	Agent - Health	12/16/2014	3/1/2017
Inactive	Northwestern Mutual Life Insurance Company	300931	Agent - Life	12/16/2014	3/1/2017

Designated to act on behalf of the following Business Entities

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Designated Agent Company Inc.	681257	Agent - Health	6/6/2016	3/1/2017
Inactive	Designated Agent Company Inc.	681257	Agent - Life	6/6/2016	3/1/2017
Inactive	Medlink Inc	400721	Agent - Health	6/6/2016	3/1/2017
Inactive	Medlink Inc	400721	Agent - Life	6/6/2016	3/1/2017