Texas Department of Insurance | www.tdi.texas.gov 1/1
FIN519 | 0421
CE AUTOMATIC FINE PAYMENT VOUCHER
This form is to be mailed with your CE fine payment. If you believe that you qualify for a fine exception, fill out form
FIN517 for consideration prior to sending in payment as penalty fines are non-refundable under the Texas
Administrative Code.
Calculating Your Automatic Fine
For each hour deficient, send $50, up to a maximum fine of $500. License terms ending prior to
06/01/2018 do not have a maximum fine and may exceed the $500 limitation.
To determine your CE deficiency, go to www.sircon.com/texas. Click on “Look up education
courses/credit,” to view your online CE transcript.
Your Information
Please complete the following:
Name of Licensee: ___________________________________________________________________________________________________
E-mail Address of Licensee: __________________________________________________________________________________________
License Number: ___________________________________________________________________________________________________
Amount of Full Fine Enclosed: __________________________________________________________________________________________
______________________________________________________________________ _______________________________________________
Signature Date
Mailing Instructions:
Make checks or money orders payable to “Texas Department of Insurance.”
Via USPS send to:
Agent and Adjuster Licensing
Texas Department of Insurance
P.O. Box 12069, MC: CO-AAL
Austin, Texas 78711-2069
Via FedEx and UPS send to:
Texas Department of Insurance
Attn: Lockbox Department
208 E. 10th Street, MC : MC-AAL
Austin, Texas 78711
Accounting: USE 462 and CRE100
PLEASE RETURN TO AGENT AND ADJUSTER LICENSING
ADMINISTRATIVE OPERATIONS, CONTINUING EDUCATION,
MAIL CODE 107-1A
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