Skip to Main Content
Contact Us Search
CA Department of Insurance
CA Department of Insurance
CA Department of Insurance

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

BCIA 8016

     LIC 442-39A

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

Variable Contract Authority Request


Clearance Letter Request


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

LIC 411-8A

Business Entity Endorsement 

LIC 411-8B Endorsee Self Termination

LIC 411-8T

Business Entity Endorsement Termination    

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  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 437-23  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)

Sircon Apply for a License

LIC 441-11

Business Entity License Application (Resident & Non-Resident)

Sircon Apply for a License

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

LIC 442-39A

     BCIA 8016
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

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 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

LIC 448-29A

Renew Individual License Application

Sircon Renewal and Reinstate a License
(This service is available for most but not all license types)

LIC 448-29B 

Renew Business Entity License Application

Sircon Renewal and Reinstate a License
(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

Sircon Renewal and Reinstate a License 
(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


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


Google Translate