Request to Surrender License

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

Contact Information:

Name/Business Name:

Address:

City: State: Zip:

Email:

National Producer Number (NPN):

License to Surrender:

Reason:

If Other, please input reason:

Requested Effective Date*:

*THIS REQUEST CAN ONLY BE SUBMITTED WITHIN 30 DAYS OF THE 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.