Producer Licensing 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 copy of the Adobe Acrobat Reader can be downloaded from our 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 |
|---|---|
|
Fingerprint Impressions – Request for Live Scan Service Important Note: Please review the Licensing Applicant Instructions, form LIC 442-39A to submit fingerprints. |
|
| CDI-179 | License Legal Certification Request |
|
Individual Application - Public Adjuster and Apprentice |
|
| CDI-181 | Business Entity Application - Public Adjuster |
| CDI-182 | Individual Application for Administrator's Certificate |
| CDI-183 | Independent Insurance Adjuster List of Employees and Adjusters Not Licensed in California |
| 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-073 |
Variable Contract Authority Request |
| LIC-074 |
Clearance Letter Request |
| LIC-075 |
California Insurance License Name Change Request |
| LIC 94A | Bond of Public Insurance Adjuster |
| LIC 0100A | Application for Public Insurance Adjuster Authorization |
| LIC 268-C | Bail Identification Card Request Form |
|
Business Entity Endorsement |
|
| LIC 411-8B | Endorsee Self Termination |
|
Business Entity Endorsement Termination |
|
| LIC 411-10 | Supplementary Application for Certificate of Convenience to Executor, Administrator, Widow, or Heir |
|
Insurance Broker Bond |
|
| LIC 417-31 | Action Notice of Solicitor |
| LIC 417-32 | Solicitor Self Termination |
| LIC 421-4 | Co-partnership - 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 437-12 | Bond of Bail Fugitive Recovery Agent |
| LIC 437-23 | Action Notice Bail Agent |
| LIC 437-23B | Bail Fugitive Recovery Agent / Appointment or Termination |
| 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 |
| Individual Application for Insurance License (Resident & Non-Resident) | |
| Business Entity License Application (Resident & Non-Resident) | |
| LIC 441-11A | Business Entity Supplemental Application |
| LIC 441-12 | Business Entity Application for Administrator's Certificate |
| 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 441-20 |
Individual Application for Life Settlement Broker License |
| LIC 441-20C |
Life Settlement Form Filing Cover Sheet |
| LIC 441-20N |
Life Producer Notification of Brokering Life Settlements |
|
Licensing Applicant Instructions Important Note: After reviewing form LIC 442-39A, complete the Request for Live Scan Service, form BCIA 8016 to submit fingerprints. |
|
| LIC 446-2 | Prelicensing/Continuing Education Program Provider Certification/Renewal Application |
| LIC 446-2A | 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 446-4A | Prelicensing/Continuing Education Program List of Instructor(s)/Subject Matter Experts 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 |
|
Change of Address Change your Address Online |
|
| 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 |
|
Name Approval Request |
|
| LIC 447-54A | Action Notice of Appointment
To submit appointments electronically contact the National Insurance Producer Registry (NIPR) and its authorized resellers for a list of approved resellers. |
| LIC 447-54T | Action Notice of Termination
To submit terminations electronically contact the National Insurance Producer Registry (NIPR) and its authorized resellers for a list of approved resellers. |
| LIC 447-69 | Agent Notice of Self Termination |
| LIC 447-70 | Bond of Cargo Shippers Agent |
| Renew Individual License Application Sircon Renewal and Reinstate a License (This service is available for most but not all license types) |
|
| Renew Business Entity License Application Sircon Renewal and Reinstate a License (This service is available for most but not all license types) |
|
| Renew Insurance Adjuster and Public Insurance Adjuster application | |
| LIC 448-29D | Renew Business Entity Adjuster and Public Insurance Adjuster application |
|
Late Renewals Only |
Renew Title Marketing Representative application
Sircon Renewal and Reinstate a License |
| LIC L 450 | Authorization to Maintain Trust Account Records at a Secondary Office Application |
| 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 |
| License Cancellation Request | |
| 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 |
| LIC TA 1 | Travel Agent - Initial Notice of Appointment |
| LIC TA 2 | Travel Agent - Initial Certification of Authorized Travel Retailers |
| LIC TA 3 | Travel Agent - Required Training Elements |
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 Producer Licensing Bureau Forms
