Request To Cancel Or Surrender License/Line of Authority


Please use this form to voluntarily cancel or surrender your license/line of authority. Please note this form only cancels your license/line of authority, effective the date we receive notice. It does not clear your license for a Clearance Letter. Producers and Service Representatives have 12 months from the date in which the license was canceled to have this license reissued. Producers and Service Representatives should contact the Alabama Department of Insurance prior to that time to have a license reissued.


Request to Cancel or Surrender License

Request to Cancel or Surrender a Line of Authority

Request to Cancel or Surrender a Line of Authority (ADJUSTERS ONLY)


Please enter your Alabama license number and an email address where we can send confirmation that your form has been uploaded successfully. Then upload your completed and signed form.

Form must be in pdf format.


Alabama Insurance License Number:
 

Email Address:
 


Please read the statement below and enter a four-digit number of your choosing in the eSignature box to show your intention to sign this document.

By electronically signing below, I do hereby swear and affirm that all information provided is true and correct. I the undersigned do understand that submission of false information is grounds for license revocation and may subject me to criminal penalties.

eSignature:

Upload Form:
 

For security purposes, you must check the checkbox below (and follow any puzzle prompts it may give you).