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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 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 446-4APrelicensing/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

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.

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