Fillable REQUEST FOR LETTER OF CLEARANCE (Arizona)

Fill Online, Printable, Fillable, Blank REQUEST FOR LETTER OF CLEARANCE (Arizona) Form

Use Fill to complete blank online ARIZONA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

REQUEST FOR LETTER OF CLEARANCE (Arizona)

On average this form takes 11 minutes to complete

The REQUEST FOR LETTER OF CLEARANCE (Arizona) form is 2 pages long and contains:

  • 1 signature
  • 3 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

BROWSE ARIZONA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
100 North 15 Avenue, Suite 261 | Phoenix, Arizona 85007-2630
Page 1 of 2
FORM L-CLR 20220601
FORM L-CLR
REQUEST FOR LETTER OF CLEARANCE
LICENSING
602-364-4457 |
insurancelicensing@difi.az.gov
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 (DRLP) below.
FULL LAST NAME
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.
Pursuant to A.R.S. § 20-289(F), I understand that I will need to
meet all new applicant requirements to obtain this authority in the future.
Section 3 How would you prefer to receive your clearance letter?
OPTION 1 – $3.00: EMAIL to the following address:
EMAIL ADDRESS:
OPTION 2 – $3.00: MAIL to the following address:
STREET ADDRESS OR PO BOX
CITY
STATE
ZIP CODE
OPTION 3 – FREE: I am only reporting the surrender of my license and do not require a paper certification letter.
PAYMENT (Do not send cash. We do not accept cash):
• Check, Cashier’s Check or Money Order payable to INSURANCE LICENSING SECTION
Number of Letters requested:
×
$ 3.00
Total Enclosed:
$
Continued on page 2…
0.00
Page 2 of 2 FORM L-CLR 20220601
Section 4 Signature
If I selected option A in section 2 above, I understand that my Arizona license will be INACTIVATED when this request is processed. I also understand
that I have 30 days from the date of my signature to apply for licensure in my new resident state and that when I receive my new resident license in
my new resident state, I must immediately notify the Arizona Department of Insurance and Financial Institutions that the new resident license has been
issued by sending an email to insurancelicensing@dif.az.gov. If I do not report the new resident license within 30 days of issuance, I understand that
I will be required to apply for a new license and pay all new license application fees.
SIGNATURE OF LICENSEE OR DRLP DATE
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

REQUEST FOR LETTER OF CLEARANCE (Arizona)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 July 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document