HAWAII
INSURANCE
DIVISION
Request for
Letter of Certification
Letter of Clearance
Name as it appears on the Hawaii license certificate
HI License No. HI Entity ID
Indicate state(s) requesting Letter(s) of Certification for:
Indicate state* requesting Letter of Clearance for:
My signature below indicates that I understand my Hawaii resident license will be inactivated,
along with any appointments, in order for a Letter of Clearance to be issued.
MAILING ADDRESS
Physical Street or P.O. Box:
City State Zip Code or Foreign Country
Signature of Licensee
1
Print Name and Title of Signer
1
For individual license, the individual must sign. For Agency, the Designated Representative named on the license must sign.
*You may only request a Letter of Clearance for one state only. This letter is used to apply for a resident license in another state
IMPORTANT NOTE: The changes indicated above will be effective upon receipt in the Hawaii Insurance Division.
Hawaii Insurance Division, 335 Merchant Street - Room 213, Honolulu, Hawaii 96813
Website: http://insurance.hawaii.gov
E-mail: InsLic@dcca.hawaii.gov
phone: 808-586-2788
fax: 808-587-6714
Form LC (06/03/2009)
