Request for Letters of Certification/Clearance
($5.00 Fee Per Letter)
Date ________________________________
Please complete the following by indicating the number and type of Certification/Clearance Letters you are
Letter of Certification on an Individual _______
Letter of Certification on an Agency _______
Letter of Clearance _______
* Please Note: When requesting a Letter of Clearance all licenses for that licensee will be terminated.
Name of Licensee_____________________________________ SSN/FEIN______________________________
Address ____________________________________________ City/State/Zip ___________________________
License No. _________________________________________ License Type ___________________________
Requested by: ________________________________________ Phone No. ______________________________
Address _____________________________________________ City/State/Zip ___________________________
Email __________________________________________
(Must be completed - Certification/Clearance Letter will be e-mailed to the requestor)
Signature _______________________________________
(Clearance Letter requests must be signed by the licensee)
NOTE: Each State Insurance Commissioner may verify the Producer’s licensing status through the National Producer
Database maintained by the National Association of Insurance Commissioners, its affiliates or subsidiaries. It may
not be necessary to request a Letter of Certification. Please check with the State in which you are applying.
1351 West North Street, Suite 101, Dover, DE 19904
Email: Phone: 302-674-7390
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