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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.

LIC 447-54T

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
Adjusters Not Licensed in California

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 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 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
(This service is available for most but not all license types)

LIC 411-8A

Business Entity Endorsement Termination

Sircon Business Entity Online Services
(This service is available for most but not all license types)

LIC 411-8T

Business Entity License Application (Resident & Non-Resident)

Sircon Business Entity Online Services
(This service is available only for Property Broker-Agent, Casualty Broker-Agent, Life Agent and Accident and Health or Sickness Agent license types.)

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
(If you are changing states, please use Form LIC 447-7)

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
Instructions, form LIC 442-39A, to submit fingerprints.

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
(This service is available for most but not all license types)

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
Instructions, form LIC 442-39A, to submit fingerprints.

BCIA 8016

LIC 442-39A

Name Approval Request

Sircon Online Business Entity Services
(Available for new Business Entity applicants only)

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

Sircon Education Provider Online Services

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
(This service is available for most but not all license types)

LIC 448-29A

Renew Business Entity License Application

Sircon Online Renewal Services
(This service is available for most but not all license types)

LIC 448-29B

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
(This service is available for most but not all license types)

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

Print your own 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

LIC TA 3

Variable Contract Authority Request

LIC-073


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.

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