Fillable Form AL-LOA (01/2013): Request to Cancel or Surrender (Alabama Department of Insurance)

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Form AL-LOA (01/2013): Request to Cancel or Surrender (Alabama Department of Insurance)

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Form AL-LOA (01/2013)
STATE OF ALABAMA – DEPARTMENT OF INSURANCE
Request to Cancel or Surrender a Line of Authority
ADJUSTER LICENSE(s) ONLY
Please use this form to voluntarily cancel or surrender a line of authority on your License. Please
note this form will only cancel the line of authority you mark below on the date that we receive it
in office. It does not clear your license for a Clearance Letter.
PLEASE CLEARLY PRINT OR TYPE
ALL INFORMATION IS REQUIRED
Licensee’s Full Name:
National Producer #, SSN, or FEIN:
Alabama License #:
Line of authority to cancel:
_____________________________________________
Line(s) of authority to keep active __________________________________________
I hereby request the cancellation of the line of authority listed effective immediately. I
understand to get this line of authority back active, I must comply with a new
application process that can be found on www.aldoi.gov
Signature Date
Fax Form To : (334) 240-3282
Email Form to: producerlicensing@insurance.alabama.gov
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Form AL-LOA (012013): Request to Cancel or Surrender (Alabama Department of Insurance)

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Completed 20 July 2020

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