Form AID-LI-AGY-TERM-TI "Title Agency Producer Termination of Affliation" - Arkansas

What Is Form AID-LI-AGY-TERM-TI?

This is a legal form that was released by the Arkansas Insurance Department - a government authority operating within Arkansas. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the Arkansas Insurance Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AID-LI-AGY-TERM-TI by clicking the link below or browse more documents and templates provided by the Arkansas Insurance Department.

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FORM AID-LI-AGY-TERM-TI (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE 501-371-2750
FAX 501-683-2604
WEBSITE
https://insurance.arkansas.gov/pages/industry-regulation/licensing/
TITLE AGENCY PRODUCER TERMINATION OF AFFLIATION
Title Agency Name: _____________________________________________________________________
Title Agency Address: ___________________________________________________________________
Title Agency Contact Name: ______________________________________________________________
Title Agency Contact Phone Number: _______________________________________________________
Agency Tax Identification Number or License #: ______________________________________________
REMOVING A TITLE AGENT FROM THE TITLE AGENCY LICENSE
Fees: All termination of affiliations are $10.00 each. Make check payable to the Arkansas Insurance Department
Title Agent’s Name: ____________________________________________________________________
Tile Agent’s License #: _________________________________________________________________
Title Agent’s Name: ____________________________________________________________________
Tile Agent’s License #: __________________________________________________________________
Title Agent’s Name: ____________________________________________________________________
Tile Agent’s License #: __________________________________________________________________
Dated_________________________________
_________________________________
SIGNATURE OF AUTHORIZED REPRESENTATIVE
_________________________________________________
PRINTED NAME OF REPRESENTATIVE
FORM AID-LI-AGY-TERM-TI (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE 501-371-2750
FAX 501-683-2604
WEBSITE
https://insurance.arkansas.gov/pages/industry-regulation/licensing/
TITLE AGENCY PRODUCER TERMINATION OF AFFLIATION
Title Agency Name: _____________________________________________________________________
Title Agency Address: ___________________________________________________________________
Title Agency Contact Name: ______________________________________________________________
Title Agency Contact Phone Number: _______________________________________________________
Agency Tax Identification Number or License #: ______________________________________________
REMOVING A TITLE AGENT FROM THE TITLE AGENCY LICENSE
Fees: All termination of affiliations are $10.00 each. Make check payable to the Arkansas Insurance Department
Title Agent’s Name: ____________________________________________________________________
Tile Agent’s License #: _________________________________________________________________
Title Agent’s Name: ____________________________________________________________________
Tile Agent’s License #: __________________________________________________________________
Title Agent’s Name: ____________________________________________________________________
Tile Agent’s License #: __________________________________________________________________
Dated_________________________________
_________________________________
SIGNATURE OF AUTHORIZED REPRESENTATIVE
_________________________________________________
PRINTED NAME OF REPRESENTATIVE