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AGENTS & BROKERS: Producer Licensing Bureau Forms By Form Number

The following producer licensing forms are listed by "Form Number." 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 our Free Document Readers web page. Additionally, forms may be revised periodically or new forms may be added, so keep checking back.

Interactive Form - Additionally, the Producer Licensing Bureau converted all of its forms from a non-interactive form to an interactive form. 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 by Form Number

Form Number	Form Title
LIC 001B	Bail Course Approval/Renewal Application
LIC 31A-9	Adjuster/Public Adjuster Personal Identification Information
LIC 31A-13	Application for Branch Office Certificate
LIC 31A-14	Bond of Insurance Adjuster
LIC 41A	Adjuster / Public Adjuster Individual License Application
LIC 42A	Adjuster / Public Adjuster Organization License Application
LIC 050	Surplus Line and/or Special Lines' Surplus Line Certification
LIC 94A	Bond of Public Insurance Adjuster
LIC 0100A	Application for Public Insurance Adjuster Authorization
LIC 268-C	Bail Identification Card Request Form
LIC 411-8A	Business Entity Endorsement Business Entity Endorsement and Termination Online Service (This service is available for most but not all license types)
LIC 411-8B	Endorsee Self Termination
LIC 411-8T	Business Entity Endorsement Termination Business Entity Endorsement and Termination Online Service (This service is available for most but not all license types)
LIC 411-10	Supplementary Application for Certificate of Convenience to Executor, Administrator, Widow, or Heir
LIC 417-5	Insurance Broker Bond (Property broker and/or Casualty broker or Personal Lines broker)
LIC 417-31	Action Notice of Solicitor
LIC 417-32	Solicitor Self Termination
LIC 421-4	Copartnership - Application for Registration
LIC 431-1	Bail License Application
LIC 431-1B	Bail License Renewal
LIC 431-2	Corporate Bail License Application
LIC 437-9	Bond of Bail Agent
LIC 437-10	Bond of Bail Permittee
LIC 437-11	Bond of Bail Solicitor
LIC 437-23	Action Notice Bail Agent
LIC 437-25	Bail Agent - Change of Corporate Stockholder, Officer, or Director
LIC 438	Action Notice Statement (Bail Agent and Permittee)
LIC 441-1	Certificate to Sell Securities as Agent
LIC 441-9	Individual Application for Insurance License (Resident & Non-Resident) Fast Licensing Application Service is Here (FLASH) (This service is available for most but not all license types)
LIC 441-11	Business Entity License Application (Resident & Non-Resident) Business Entity Online License Application (This service is available for Property Broker-Agent and Casualty Broker-Agent, Life-Only Agent and Accident and Health Agent license types only)
LIC 441-11A	Business Entity Supplemental Application
LIC 441-12	Administrator Certificate (RA) Application
LIC 441-14	Reinsurance Intermediary Broker/Manager/Individual Application
LIC 441-15	Reinsurance Intermediary Broker/Manager/Organization Application
LIC 441-17	Individual Application - Short Form
LIC 442-39A	Request for Live Scan Service
LIC 446-2	Prelicensing/Continuing Education Program Provider Certification/Renewal Application
LIC 446-3	Prelicensing/Continuing Education Program Course Approval Application
LIC 446-4	Prelicensing/Continuing Education Program Instructor Qualification Form
LIC 446-5	Prelicensing/Continuing Education Program Course Attendance Record and Verification Form
LIC 446-8	Prelicensing Education Requirements
LIC 446-9	California Tax Qualified Long-Term Care, California Partnership & Workers' Compensation Continuing Education Requirements
LIC 446-12	Class Presentation Schedule
LIC 446-13	Provider Roster Education Provider Online Programs
LIC 446-32	Prelicensing/Continuing Education Program Stipulation to Maintain Records Outside of California
LIC 446-40	Prelicensing/Continuing Education Program Out-of-State Provider Jurisdiction Agreement
LIC 446-42	Education Provider - Address Change
LIC 447-7	Change of Address Change your Address Online (If you are changing states, please use Form LIC 447-7)
LIC 447-8	Electronic Filing Exemption of Insurer Appointment and Termination
LIC 447-31	Bond of Surplus Lines Broker
LIC 447-32	Bond of Special Lines' Surplus Lines Broker
LIC 447-42A	Name Approval Request Name Approval Request Online Services (Available for new Business Entity applicants only)
LIC 447-54A	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 447-54T	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 447-69	Agent Notice of Self Termination
LIC 447-70	Bond of Cargo Shippers Agent
LIC 448-29A	Renew Individual License Application Free Application Online Renewal Service (This service is available for most but not all license types)
LIC 448-29B	Renew Business Entity License Application Free Application Online Renewal Service (This service is available for most but not all license types)
LIC 448-29C	Renew Insurance Adjuster and Public Insurance Adjuster application
LIC 448-29D	Renew Business Entity Adjuster and Public Insurance Adjuster application
Late Renewals Only LIC 448-29E	Renew Title Marketing Representative application Free Application Online Renewal Service) (This service is available for most but not all license types)
LIC L 450	Authorization to Maintain Trust Account Records at a Secondary Office Application
LIC 780	Request for Certificate of License Status Print your own Certificate of License Status
LIC 2557B	Background Information Change Disclosure Form
LIC BED-1	Business Entity Disclosure
LIC CC1	Certification of Coverage for Limited Liability Companies
LIC CC1B	Annual Certification of Coverage for Limited Liability Companies
LIC CI 10	Credit Insurance Agent The Annual Training Material Submission Form
LIC CI 20	Credit Insurance Agent Notice of Appointment
LIC CI 30	Credit Insurance Agent The Outline for Required Training Elements
LIC CI 40	Credit Insurance Agent Annual Certification of Endorsee Training and List of Endorsees
LIC CI 50	Credit Insurance Agent Employee's Affidavit of Training and Knowledge
LIC PE 1	Notice of Appointment - Portable Electronics Insurance Agent
LIC PE 2	Authorized Locations - Portable Electronics Insurance Agent
LIC RCA 1	Initial Certification - Rental Car Agency
LIC RCA 2	Annual Certification - Rental Car Agency
LIC RCA 3	Notice of Appointment - Rental Car Agency
LIC RCA 4	Required Training Elements - Rental Car Agency
LIC RCA 5	Authorized Endorsees - Rental Car Agency
LIC SSA 1	Authorized Endorsee - Self Service Storage Facility
LIC SSA 2	Notice of Appointment - Self-Service Storage
LIC SSA 3	Required Training Elements - Self-Service Storage Facility
Provider Summary Notice	Provider Summary Notice
§§ 2050-2698.86	Title 10 Regulations

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 Producer Licensing Bureau 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.