Sircon's Additional State Service Requests Instructions
Steps to Submit the Complete Form
Please review and select the paper form you would like to submit electronically. Ensure that you have the attachments ready when you access Sircon’s “Additional State Service Requests” online services. The paper form selected with additional required items attached that can be submitted and the fees paid electronically:
- Agent Appointment/Affiliation Self-Termination, LIC 447-69
- Agent Endorsee/Association Self-Termination Notice, LIC 411-8B
- Agent Solicitor/Sponsorship Self-Termination Notice, LIC 417-32
- Bond on Cargo Shipper's Agent, LIC 447-70
- Bond of Insurance Broke, LIC 417-5
- Bond of Special Lines' Surplus Line Broker, LIC 447-32
- Bond of Surplus Line Broker, LIC 447-31
- Clearance letter, LIC 074
- Surplus Line Endorsements Only – Business Entity Endorsement, LIC 411-8A
Agent Appointment/Affiliation Self-Termination, LIC 447-69
The Agent Notice of Termination, LIC 447-69, authorizes an individual agent who is appointed by an insurer to self-terminate that appointment.
- No additional required items
- Complete the Agent Notice of Termination, LIC 447-69
- On the “Attach the completed form for this request” web page, attach the completed LIC 447-69
- Submit the form using the “Process” button and proceed to the payment web page to pay the fee electronically
Agent Endorsee/Association Self-Termination Notice, LIC 411-8B
Endorsee Self Termination Notice, LIC 411-8B, authorizes an individual agent who is endorsed by a business entity to self-terminate that business entity endorsement /association.
- No additional required items
- Complete the Endorsee Self Termination Notice, LIC 411-8B
- On the “Attach the completed form for this request” web page, attach the completed LIC 411-8B
- Submit the form using the “Process” button and proceed to the payment web page to pay the fee electronically
Agent Solicitor/Sponsorship Self-Termination Notice, LIC 417-32
The Solicitor Self Termination Notice, LIC 417-32, authorizes an individual agent who is appointed as a solicitor for a property and/or casualty or personal lines broker-agent to self-terminate the sponsoring solicitor appointment.
- No additional required items
- Complete the Solicitor Self Termination Notice, LIC 417-32
- On the “Attach the completed form for this request” web page, attach the completed LIC 417-32
- Submit the form using the “Process” button and proceed to the payment web page to pay the fee electronically
Bond of Cargo Shipper's Agent, LIC 447-70
The Bond of Cargo Shipper’s Agent, LIC 447-70, is required to demonstrate the financial responsibility of an individual cargo shipper's agent to fulfill their obligations and responsibilities when acting on behalf of cargo owners and cargo shippers.
- The completed LIC 447-70
- Please note, this bond requires the following items to be included with the bond when the LIC 447-70 is attached on the web page stating, “Attach the completed form for this request:”
- The Power of Attorney (if the bond was not executed by an officer of the insurer)
- The Jurat (if the Seal of Surety Corporation was not included in the Power of Attorney)
- On the “Attach the completed form for this request” web page, attach the completed LIC 447-70, and, if required, the Power of Attorney and Jurat
- Submit the form(s) using the “Process” button and proceed to the payment web page to pay the fee electronically
Bond of Insurance Broker, LIC 417-5
The Bond of Insurance Broker, LIC 417-5, is required for individual property, casualty, and personal lines licensees seeking to be licensed as an insurance broker.
- Complete the Bond of Insurance Broker, LIC 417-5
- Please note, this bond requires the following items to be included with the bond when the LIC 417-5 is attached on the web page stating, “Attach the completed form for this request:”
- The Power of Attorney (if the bond was not executed by an officer of the insurer)
- The Jurat (if the Seal of Surety Corporation was not included in the Power of Attorney)
- On the “Attach the completed form for this request,” web page, attach the completed LIC 417-5, and, if required, the Power of Attorney and Jurat
- Submit the form(s) using the “Process” button and proceed to the payment web page to pay the fee electronically
Bond of Special Lines' Surplus Line Broker, LIC 447-32
Bond of Special Lines’ Surplus Line Broker, LIC 447-32, must be maintained for individuals to be licensed in California as a special lines surplus line broker to ensure the broker will account for and pay premiums collected for insurance policies other than life.
- The completed LIC 447-32
- Please note, this bond requires the following items to be included with the bond when the LIC 447-32 is attached on the web page stating, “Attach the completed form for this request:”
- The Power of Attorney (if the bond was not executed by an officer of the insurer)
- The Jurat (if the Seal of Surety Corporation was not included in the Power of Attorney)
- On the “Attach the completed form for this request” web page, attach the completed LIC 447-32, and, if required, the Power of Attorney and Jurat
- Submit the form(s) using the “Process” button and proceed to the payment web page to pay the fee electronically
Bond of Surplus Line Broker, LIC 447-31
The Bond of Surplus Line Broker, LIC 447-31, is required for individual Surplus Line Brokers who are not transacting under the authority of a Surplus Line business entity.
- Please note, this bond requires the following items to be included with the bond when the LIC 447-31 is attached on the web page stating, “Attach the completed form for this request:”
- The completed Surplus Lines and/or Special Lines’ Surplus Lines Endorsement Authorization, LIC-050
- The Power of Attorney (if the bond was not executed by an officer of the insurer)
- The Jurat (if the Seal of Surety Corporation was not included in the Power of Attorney)
- On the “Attach the completed form for this request” web page, attach the completed LIC 447-31, the completed LIC-050, and, if required, the Power of Attorney and Jurat and press “Continue”
- Submit the form(s) using the “Process” button and proceed to the payment web page to pay the fee electronically
Clearance letter, LIC-074
The Clearance Letter Request, LIC-074, authorizes California resident individual licensees to request a clearance letter to cancel their license when the resident individual licensee is moving to a new resident state that requires the California license to be cancelled before the new resident license can be issued.
- No additional documents required.
- Complete the Clearance Letter, LIC-074
- On the “Attach the completed form for this request” web page, attach the completed LIC-074
- Submit the form using the “Process” button and proceed to the payment web page to pay the fee electronically
Solicitor Appointment or Termination, LIC 417-31
The Action Notice of Solicitor Appointment or Termination, LIC 417-31, is used by an individual licensed property and/or casualty or personal lines broker-agent (employing broker-agent) to appoint and authorize an agent to act as an insurance solicitor for the employing broker-agent to assist in transacting insurance other than life, accident and health or sickness. This form is also used by the employing broker-agent to terminate a solicitor's appointment.
- No additional documents required
- Complete the Solicitor Appointments or Termination, LIC 417-31
- On the “Attach the completed form for this request” web page, attach the completed LIC 417-31
- Submit the form using the “Process” button and proceed to the payment web page to pay the fee electronically
Surplus Line Endorsements Only – Business Entity Endorsement, LIC 411-8A
The Business Entity Endorsement, LIC 411-8A, form is used by business entities to endorse individual surplus lines agents to be authorized to transact surplus lines insurance on the business entity’s behalf.
To ensure the endorsement includes the required documents, the business entity will need to:
- The Business Entity is to complete the Endorsement Form, LIC 411-8A.
- Use the individual’s state, name, and license number to enable the business entity to submit its completed LIC 411-8A
- On the “Attach the completed form for this request” web page, attach the completed LIC 411-8A and the individual agent’s completed Surplus Lines and/or Special Lines’ Surplus Lines Endorsement Authorization, LIC-050
- Submit the form(s) using the “Process” button and proceed to the payment web page to pay the fee electronically
Steps to Access the Additional State Service Requests Online Services
To access the “Additional State Service Requests” online service, please use the following three steps:
- Visit www.sircon.com/california
- Select the – “Additional State Service Requests” link in the center column
- After opening the link, insert “California” in the space provided, the licensee’s last name, the licensee’s California license number, and select “Continue.” The licensee will be in the online service portal where the forms listed above are available to submit and pay the fee electronically.
After completing the form and processing the payment online, this new online service electronically submits the form, additional required documents, and proof of payment to the Department’s Licensing Processing Section for the technician to begin their review of the documents received.
Contact Information
Please direct questions send an e-mail to CDIlicensing@insurance.ca.gov or call the Department’s Licensing Hotline at (800) 967-9331.
