DEPARTMENT OF INSURANCE

Name	Collins, Chapin Ford	DOIID	378028	NAIC NPN	549486

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Active	Resident	Agent	Variable Life and Variable Annuities	5/31/2001		10/31/2024
Active	Resident	Agent	Health	1/25/1995		10/31/2024
Active	Resident	Agent	Life	1/25/1995		10/31/2024
Active	Resident	Agent	Casualty	8/15/2000		10/31/2024
Active	Resident	Agent	Property	8/15/2000		10/31/2024
Inactive	Resident	Agent	Health Maintenance Organization	1/17/1997	3/1/2001
Inactive	Resident	Agent	Prepaid Dental Plan	3/17/2000	3/1/2001
Inactive	Resident	Agent	General Lines	2/3/1995	8/15/2000
Active	Resident	Life & Health Consultant	Not Applicable	9/7/2012		10/31/2024

*If a status is Pending, Pending Replacement,or the record displays Affidavit on File, click on them for more details.

Notice: The Department verifies, at the time of application for a Variable Life and Variable Annuity line of authority, that an agent is registered with the Financial Industry Regulatory Authority (FINRA) and the applicant has passed the Series 6 or greater exam. The Department does not verify registration with FINRA after the agent is qualified by the Department to receive the Variable Life and Variable Annuity line of authority. If you have questions about a broker’s FINRA registration status, you should check this status directly with FINRA.

License Renewal Information

Class	Invoice Date	Response Due / Expiration Date	Response Received Date	Payment Received Date	Renewal Complete
Agent	08/15/2024	10/31/2024
Life & Health Consultant	08/15/2024	10/31/2024

NOTE: Licensee may renew up to 6 months prior to Next Compliance Date. Licensees subject to CE must complete CE requirements before Next Compliance Date in order to successfully complete the License Renewal Process.

Address Information

Type	Address
Business / Home Office	401 W Main St Ste 1200 Louisville, KY 402024222
Residence	Not Public Information

Phone Information

Type	Phone
Business / Home Office	(502) 736-6955