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:
Please read the statement below and check the box.
I understand that the licensee signature is required for this form to be processed.
For security purposes, you must check the checkbox below (and follow any puzzle prompts it may give you).
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