Fillable FORM L-CLR: REQUEST FOR LETTER OF CLEARANCE: (Arizona)

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FORM L-CLR: REQUEST FOR LETTER OF CLEARANCE: (Arizona)

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Page 1
L-CLR Rev 06/2018
Licensing Section
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-4457 | Toll-free: (877) 660-0964
Web: https://insurance.az.gov | E-mail: Licensing@azinsurance.gov
FORM L-CLR: REQUEST FOR LETTER OF CLEARANCE
Must be completed by the licensee or the designated responsible producer (DRP) of a business entity.
SECTION 1: Information About the License Holder
License holder is (
check one box)
:
an INDIVIDUAL
a BUSINESS ENTITY
AZ License No. (AZ license holder)
State to which licensee is relocating:
If the license holder is a BUSINESS ENTITY, enter the name (otherwise leave blank):
• If the license holder is an INDIVIDUAL, enter information for that individual below.
•
If the license holder is a BUSINESS ENTITY, enter information for the designated responsible producer (DRP) below.
FULL First Name:
Middle Initial:
AZ License No. (if applicable):
SECTION 2: Reason for the Request (Select EITHER Box A or Box B)
A:
I AM RELOCATING TO ANOTHER STATE and would like to change from being a resident licensee in Arizona to
being a non-resident licensee in Arizona. Please provide your new contact information below.
BUSINESS
ADDRESS
Business Name (if applicable)
Phone Number with area code
Physical Street Address
City
State
ZIP Code
MAIL ADDRESS
Business Name (if applicable)
Business Email Address
Street Address or PO Box
City
State
ZIP Code
HOME ADDRESS
(if INDIVIDUAL
license holder)
Physical Street Address
City
State
ZIP Code
Home Email Address
Phone Number with area code
B:
I AM SURRENDERING MY ARIZONA LICENSE. I understand that I will not be allowed to reapply for an Arizona
Insurance license for at least one year after the surrender date per A.R.S. § 20-289(F).
SECTION 3: How would you prefer to receive your clearance letter?
OPTION 1 – $3.00: CALL me for pick up. Enter phone number ……….
Phone number with area code:
OPTION 2 – $3.00: MAIL to the following address (allow one to three weeks for processing):
Street Address or PO Box
City
State
ZIP Code
OPTION 3 – FREE: I am only reporting the cancelation of my license and do not require a paper certification letter.
PAYMENT (Do not send cash. We do not accept cash):
Number of Letters requested:
•
Check, Cashier’s Check or Money Order payable to INSURANCE LICENSING SECTION
×
$ 3.00
• Credit Card only if paying in person. We do not accept American Express.
Total Enclosed:
$
SIGNATURE OF LICENSEE OR DRP DATE
0.00
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FORM L-CLR: REQUEST FOR LETTER OF CLEARANCE: (Arizona)

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Completed 12 August 2020

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