Request to Surrender License

Please complete the following information to surrender your insurance producer license.
All fields are required.

 


Contact Information:
Name:
Address:
City: State: Zip:
Email:
National Producer Number (NPN):
Requested Effective Date*:
*Date cannot be prior to date of request nor after the licensee’s biennial renewal date.

 

The Department no longer processes company appointments and terminations. To terminate your company appointments, please reach out to the company and request termination.

If all the above information is correct, please press the Submit button.