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. |
|
| 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 |
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 Fugitive Recovery Agent/Appointment or Termination | LIC 437-23B |
| 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 Fugitive Recovery Agent | LIC 437-12 |
| 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 |
|
|
Business Entity Endorsement Termination Sircon Business Entity Online Services |
LIC 411-8T |
|
Business Entity License Application (Resident & Non-Resident) Sircon Business Entity Online Services |
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 |
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 |
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 |
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 |
BCIA 8016 LIC 442-39A |
|
Name Approval Request Sircon Online Business Entity Services |
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 |
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 |
LIC 448-29A |
|
Renew Business Entity License Application Sircon Online Renewal Services |
|
| 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 |
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 |
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 | |
| Variable Contract Authority Request |
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.
