Department of Insurance
State of California
Business Entity Endorsement
LIC 411-8A (Rev 1/2021)
Producer Licensing Bureau
P.O. Box 1139
Sacramento, CA 95812-1139
(800) 967-9331
www.insurance.
ca.gov
Pursuant to Section 1627 and 1661 of the Insurance Code
Business Entity Name: License Number
Mailing Address:
To the Insurance Commissioner of the State of California: Effective from the date of filing this notice, the Business Entity hereby endorses
the person(s) named to exercise the agency or brokerage powers of the business entity.
Note: Enter only one endorsement type per line. (Exception SL/SP)
*AH - Accident and Health Agent or Sickness *LO - Life Agent *VC - Variable Contract Authority LI - Life-Limited to the Payment of Funeral & Burial
Expenses *PR - Property Broker Agent *CA - Casualty Broker-Agent AU - Limited Lines Automobile Insurance Agent LA - Life and Disability Analyst
CS - Cargo Shipper’s Agent **CI - Credit Insurance Agent PL - Personal Lines Broker Agent MC - Motor Club Agent SL - Surplus Line Broker SP -
Special Lines’ Surplus Line Broker SL/SP - Surplus Line & Special Lines’ Surplus Line Broker LS - Life Settlement Broker
**Endorsement
Type
Endorsee’s Social
Security Number****
Endorsee’s Name
(as shown on license)
Effective Date
of Endorsement
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Signature and title of authorized representative.
►
Title: Date:
E-mail: Phone Number: ( )
Filing fee: Submit $32 filing fee per endorsement type. Enter number of endorsements: X $32 $
Please note, if you are endorsing an applicant for an insurance license, submit only one name per form and attach the form to the application.
1.
If you are submitting only an endorsement:
Mail Endorsement form and fee to► California Department of Insurance, P.O. Box 311, Sacramento, CA 95812-0311
or
2. If endorsement is being subm
itted with original application
Mail Endorsement form with application and fee to► California Department of Insurance, P.O. Box 1139, Sacramento, CA 95812-1139
*If endorsing Life Agent and/or Accident and Health or Sickness and/or Variable Life and Variable Annuity submit only one filing fee or if endorsing
Property Broker-Agent and Casualty Broker-Agent, submit only one filing fee
** For Credit Insurance applicants only: submit $45 per endorsement.
*** There is no fee for the Life Settlement Broker.
**** Disclosure of your U. S. social security numb
er is mandatory pursuant to Cal. Civil Code, § 1798.17; Cal. Family Code, § 17520(d); and Federal
Privacy Act of 1974, §§7(a) (2) (B) and 7(b). Your social security
number will be used primarily for purposes of processing your application, including
conducting any necessary investigation into your background. If you fail to disclose your social security number, your application will not be reviewed.
An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information
regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone
(800-967-9331) or by mail, to the following address: 320 Capitol Mall, Sacramento CA 95814.
