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Frequently Requested Forms

Listed below are the Producer Licensing Bureau's frequently requested agent licensing forms. These forms are available only 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 Documents Readers website. Additional forms will be added or revised periodically, so keep checking back. For instructions on completing the forms please click on the name of the form. All forms on this page are interactive. Many of these forms can now be filed using various online services.

Form Title

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PDF Format

Action Notice of Appointment

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

  LIC 447-54A 

Action Notice of Termination

To submit terminations electronically contact the National Insurance Producer Registry (NIPR) and its authorized resellers for a list of active resellers

  LIC 447-54T 

Background Information Change Disclosure Form

  LIC 2557B 

Business Entity Endorsement Appointment

Sircon's Maintain Agency Associations

  LIC 411-8A 

Business Entity Endorsement Termination

Sircon's Maintain Agency Associations

  LIC 411-8T 

Business Entity License Application

Sircon's Apply for a LIcense

  LIC 441-11 

Change of Address

Sircon's Change an Address
(If you are changing resident states, please use paper Form LIC 447-7)

  LIC 447-7 

Property and/or Casualty Broker Bond 

  LIC 417-5

Individual Insurance License Application

Sircon's Apply for a License

  LIC 441-9 

Renew or Reinstate Individual License Application

Sircon's Renew or Reinstate a License

  LIC 448-29A 

Renew or Reinstate Business Entity License Application

Sircon's Renew or Reinstate a License

  LIC 448-29B 

Request for Certificate of License Status

Sircon's Request a Letter of Certification

  LIC 780 


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 Producer Licensing Bureau. Please be sure to include your name, telephone number, license number and e-mail address in all correspondence with the CDI.

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