Fillable LICENSE SURRENDER FORM (Department of Technology and Information)

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LICENSE SURRENDER FORM (Department of Technology and Information)

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The LICENSE SURRENDER FORM (Department of Technology and Information) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Department of Technology and Information

BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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LICENSE SURRENDER FORM
INSTRUCTIONS:
All areas of this form that relates to the individual or agency must be completed. Do not combine an
individual and business entity on the same form. Combinations will not be processed. If this from is not signed and dated,
we will not process the request.
COMPLETED FORM MAY BE
MAILED:
Delaware Insurance Department, Attention: Producer Licensing, 841 Silver Lake Blvd., Dover, DE 19904
FAXED:
302-736-7906
EMAILED
: licensing@state.de.us
INDIVIDUAL:
Name: ______________________________________________________________________________
License Type: _____________________________________________________
Delaware License Number: ___________________________________________ or
National Producer Number: __________________________________________
Please accept this as my request to voluntarily surrender my Delaware Insurance License.
__________________________________________ Dated: ______________________________
Licensee’s Signature
BUSINESS ENTITY (AGENCY):
Name: _______________________________________________________________________________
License Type: ____________________________________________________
Delaware License Number: _________________________________________ or
National Producer Number: ________________________________________
Please accept this as my request to voluntarily surrender the Delaware Insurance License. I am authorized to act
on behalf of the above agency and have authority to make this request.
______________________________________________ Dated: __________________________
Signature of Authorized Agency Representative
______________________________________________
Printed Name of Authorized Agency Representative
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LICENSE SURRENDER FORM (Department of Technology and Information)

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Completed 13 August 2020

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