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Producer Licensing Forms in Alphabetical Order

The following producer licensing forms are listed in "Alphabetical Order." These forms are available in Adobe's Portable Document Format (PDF). To view and complete these PDF forms on your browser you must have Adobe Acrobat Reader on your computer. A free copy of the Adobe Acrobat Reader can be downloaded from the Free Document Readers  Web . Additionally, forms may be revised periodically or new forms may be added, so keep checking back.

Interactive Forms: Additionally, the Producer Licensing Bureau converted all of its forms to be interactive. An interactive form allows users of the CDI Website to type the information onto the application while on their computer before printing the form. 

Producer Licensing Bureau Forms Alphabetical by Title

Form Title Download PDF Form Here 

Action Notice of Appointment

To submit appointments electronically contact the National Insurance Producer Registry (NIPR) and its authorized business partners for a list of approved partners.

    LIC 447-54A
Action Notice of Solicitor     LIC 417-31

Action Notice of Termination

To submit terminations electronically contact the National Insurance Producer Registry (NIPR) and its authorized business partners for a list of approved partners.

    LIC 447-54T 

Action Notice Statement (Bail Agent or Permittee)     LIC 438 
Action Notice Bail Agent     LIC 437-23 
Adjuster  

Adjuster Individual License Application

    LIC 41A 

Adjuster Organization License Application

    LIC 42A 

Independent Insurance Adjuster List of Employees and
Adjusters Not Licensed in California

    CDI-183

Adjuster/Public Adjuster Personal Identification Information

    LIC 31A-9 

 Business Entity Application - Public Adjuster

    CDI-181 

 Individual Application - Public Adjuster and Apprentice 
License

    CDI-180
Agent Notice of Termination (self)     LIC 447-69 
Annual Certification of Coverage for Limited Liability Companies     LIC CC1B 
Application for Public Insurance Adjuster Authorization     LIC 0100A
Authorization to Maintain Trust Account Records at a Secondary Office Application     LIC L 450 
Background Information Change Disclosure Form     LIC 2557B 
Bail Agent - Change of Corporate Stockholder, Officer, or Director     LIC 437-25 
Bail Corporate License Application     LIC 431-2 
Bail Course Approval/Renewal Application     LIC 001B
Bail Identification Card Request Form     LIC 268-C 
Bail License Application     LIC 431-1 
Bail License Renewal     LIC 431-1B 
Bond of Bail Agent     LIC 437-9
Bond of Bail Permittee     LIC 437-10 
Bond of Bail Solicitor     LIC 437-11 
Bond of Cargo Shippers Agent     LIC 447-70 

Bond of Insurance Broker

(Property broker and/or Casualty broker or Personal Lines broker)

    LIC 417-5
Bond of Insurance Adjuster     LIC 31A-14 
Bond of Public Insurance Adjuster     LIC 94A 
Bond of Special Lines' Surplus Lines Broker     LIC 447-32 
Bond of Surplus Lines Broker     LIC 447-31 
Branch Office Certificate Application     LIC 31A-13 
Business Entity Application for Administrator's Certificate     LIC 441-12
Business Entity Disclosure     LIC BED-1 

Business Entity Endorsement

Sircon Business Entity Online Services
(This service is available for most but not all license types)

    LIC 411-8A

Business Entity Endorsement Termination

Sircon Business Entity Online Services
(This service is available for most but not all license types)

    LIC 411-8T

Business Entity License Application (Resident & Non-Resident)

Sircon Business Entity Online Services
(This service is available only for Property Broker-Agent, Casualty Broker-Agent, Life Agent and Accident and Health or Sickness Agent license types.)

    LIC 441-11 

Business Entity Supplemental Application     LIC 441-11A 

California Insurance License Name Change Request

    LIC-075
California Tax Qualified Long-Term Care, California Partnership  & Workers Compensation Continuing Education Requirements     LIC 446-9
Certificate of Convenience - Supplementary Application for Executor, Administrator, Widow, or Heir     LIC 411-10 
Certification of Coverage for Limited Liability Companies     LIC CC1 
Certificate to Sell Securities as Agent     LIC 441-1 

Change of Address

Change your Address Online
(If you are changing states, please use Form LIC 447-7)

    LIC 447-7

Class Presentation Schedule     LIC 446-12 

Clearance Letter Request

    LIC-074 
Co-Partnership - Application for Registration     LIC 421-4 
Credit Insurance Agent Annual Certification of Endorsee Training and List of Endorsees     LIC CI 40 
Credit Insurance Agent Employee's Affidavit of Training and Knowledge     LIC CI 50
Credit Insurance Agent The Annual Training Material Submission Form     LIC CI 10 
Credit Insurance Agent Notice of Appointment     LIC CI 20 
Credit Insurance Agent The Outline for Required Training Elements     LIC CI 30
Education Provider - Change of Address     LIC 446-42 
Electronic Filing Exemption of Insurer Appointment and Termination     LIC 447-8
Endorsee Self Termination     LIC 411-8B

Fingerprint Impressions - Live Scan Service Request

     Important note: Please review the Licensing Applicant
     Instructions, form LIC 442-39A, to submit fingerprints.

    BCIA 8016
    
    LIC 442-39A
Independent Insurance Adjuster List of Employees and Adjusters Not Licensed in California     CDI-183
Individual Application for Administrator's Certificate     CDI-182

Individual Application for Insurance License (Resident & Non-Resident)

Sircon Online Licensing Services
(This service is available for most but not all license types)

    LIC 441-9 

Individual Application - Public Adjuster and Apprentice License

    CDI-180
Individual Application for Insurance License - Short Form     LIC 441-17

Legal Certification Request

    CDI-179

License Cancellation Request

    LIC CC2

Life Settlement Form Filing Cover Sheet     LIC 441-20C
Life Producer Notification of Brokering Life Settlements     LIC 441-20N
Live Scan Service Request     
     
     Important note: Please review the Licensing Applicant
     Instructions, form LIC 442-39A, to submit fingerprints.
    BCIA 8016
    
    LIC 442-39A

Name Approval Request

Sircon Online Business Entity Services
(Available for new Business Entity applicants only)

    LIC 447-42A 

Parties Interested in the Pre-licensing & Continuing Education Program Provider Summary Notice     Provider Summary Notice
Portable Electronics Insurance Agent - Notice of Appointment

    LIC PE 1

Portable Electronics Insurance Agent - Authorized Locations

    LIC PE 2

Prelicensing/Continuing Education Program Course Approval Application     LIC 446-3
Prelicensing/Continuing Education Program Course Attendance Record and Verification Form     LIC 446-5 
Prelicensing/Continuing Education Program Instructor Qualification Form     LIC 446-4 
Prelicensing/Continuing Education Program List of Instructor(s)/Subject Matter Experts Form     LIC 446-4A 
Prelicensing/Continuing Education Program Out-of-State  Provider Jurisdiction Agreement     LIC 446-40 
Prelicensing/Continuing Education Program Provider Certification/Renewal Application     LIC 446-2 
Prelicensing/Continuing Education Program Provider Certification/Renewal Application     LIC 446-2A
Prelicensing/Continuing Education Program Stipulation to Maintain Records Outside  of California     LIC 446-32 
Prelicensing Education Requirements     LIC 446-8

Provider Roster

Sircon Education Provider Online Services

    LIC 446-13 

Reinsurance Intermediary Broker/Mgr./Individual Application     LIC 441-14 
Reinsurance Intermediary Broker/Manager/Organization Application     LIC 441-15 

Renew Individual License Application

Sircon Online Renewal Services
(This service is available for most but not all license types)

    LIC 448-29A

Renew Business Entity License Application

Sircon Online Renewal Services
(This service is available for most but not all license types)

    LIC 448-29B

Renew Individual Insurance Adjuster and Public Insurance Adjuster application     LIC 448-29C
Renew Business Entity Insurance Adjuster and Public Insurance Adjuster application

    LIC 448-29D

Renew Title Marketing Representative application

Sircon Online Renewal Services
(This service is available for most but not all license types)

    License certificate reinstatement only
    LIC 448-29E

Car Rental Agency - Annual Certification     LIC RCA 2 
Car Rental Agency - Authorized Endorsees     LIC RCA 5 
Car Rental Agency - Initial Certification     LIC RCA 1 
Car Rental Agency - Car Rental Agent Notice of Appointment     LIC RCA 3 
Car Rental Agency - Outline of Required Training Elements     LIC RCA 4

Request for Certificate of License Status

Print your own Certificate of License Status

    LIC 780 
Self-Service Storage Facility - Authorized Endorsees     LIC SSA 1 
Self-Service Storage - Notice of Appointment     LIC SSA 2 
Self-Service Storage Facility - Required Training Elements     LIC SSA 3
Solicitor Self Termination     LIC 417-32
Surplus Line and/or Special Lines' Surplus Line Endorsement Authorization     LIC-050 
Travel Agent - Initial Certification of Authorized Travel Retailers      LIC TA 2
Travel Agent - Initial Notice of Appointment      LIC TA 1
Travel Agent - Required Training Elements

     LIC TA 3

Variable Contract Authority Request

     LIC-073


Return to Producer Licensing Bureau Forms Main Page

If you have any questions about the license information you retrieved, please see the most commonly asked questions in our License Questions and Answers section. If you need further assistance, please call CDI's Licensing Hotline at (800) 967-9331 or send an e-mail to the Producer Licensing Bureau. Please be sure to include your name, telephone number, license number and e-mail address in all correspondence with the Department.

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