Fillable Form AL-PSA (04/2019): Cancellation of Appointment for Preneed (Alabama Department of Insurance)

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Form AL-PSA (04/2019): Cancellation of Appointment for Preneed (Alabama Department of Insurance)

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Form AL-PSA (04/2019)
STATE OF ALABAMA – DEPARTMENT OF INSURANCE
Cancellation of Appointment for Preneed Sales Agent
Please use this form to cancel Preneed License Appointment.
PLEASE CLEARLY PRINT OR TYPE
ALL INFORMATION IS REQUIRED
{PLEASE NOTE IF YOU ARE CANCELLING THE PSA’S ONLY APPOINTMENT, IT WILL
CANCEL THE PRENEED LICENSE ALSO}
Funeral Home Name: ___________________________________________________
FEIN: __________________________ NAIC#: __________________________
Name of PSA: ____________________________ License#: __________________
Name of PSA: ____________________________ License#: __________________
Name of PSA: ____________________________ License#: __________________
Name of PSA: ____________________________ License#: __________________
Name of PSA: ____________________________ License#: __________________
Signature Date
Email Form to: producerlicensing@insurance.alabama.gov
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Form AL-PSA (042019): Cancellation of Appointment for Preneed (Alabama Department of Insurance)

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Completed 20 July 2020

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