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: Click to Choose License Type Car Rental Limited License Credit Limited License Lines of Authority - input lines below Portable Electronic Limited License Producer License Public Adjuster Reinsurance Intermediary Surplus Lines Viatical Broker

If Lines of Authority, please input:

Reason: Click to Choose Reason Moving to Kansas No longer working as a producer Retirement Other

If Other, please input reason:

If moving to Kansas, provide date of move and the state you are moving from:

Requested Effective Date*:

*Only requests submitted within 30 days of the effective date and an active license status will be processed.

Requestor's Name:

Requestor's Email Address:

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