Form AID-LI-LS "License Surrender Form" - Arkansas

What Is Form AID-LI-LS?

This is a legal form that was released by the Arkansas Insurance Department - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

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 printable version of Form AID-LI-LS by clicking the link below or browse more documents and templates provided by the Arkansas Insurance Department.

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Download Form AID-LI-LS "License Surrender Form" - Arkansas

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fFORM AID-LI-LS (Rev. 06-2021)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 Commerce Way, Ste 104
Little Rock, AR 72202
PHONE: 501-371-2750
Website:
https://insurance.arkansas.gov/pages/industry-regulation/licensing/
Email:
Insurance.Licensing@arkansas.gov
LICENSE SURRENDER FORM
INSTRUCTIONS: Completed/signed form may be scanned/emailed (address above). All areas of this form that
relate to the individual or the agency must be completed. If information does not apply, then mark the section N/A.
WE MUST HAVE A PHYSICAL ADDRESS FOR THE RESIDENCE. Use a separate form for each license type,
individual or agency – do not combine an individual and an agency on the same form. Combinations will not be
processed. This form must be completed in ink, typed, or computer generated. The form must be legible, or it will
not be processed. This form must be signed in order to be effective.
INDIVIDUAL:
Name: __________________________________________________________________________________
Arkansas License Number: __________________________________________________________________
License Type:___Producer___________________________________________________________________
Current Mailing Address: ____________________________________________________________________
Current Residence Address: ___________________________________________________________________
Street Number and Name
City
State
Zip
Please accept this as my request to voluntarily surrender my Arkansas producer license and change my license
status to inactive.
__________________________________________________
Dated: ______________________________
Licensee’s Signature
BUSINESS ENTITY (AGENCY):
Name: __________________________________________________________________________________
Arkansas License Number: _________________________________________________________________
Current Mailing Address: __________________________________________________________________
Current Physical Address: __________________________________________________________________
Street Number and Name
City
State
Zip
Please accept this as my request to voluntarily surrender the Arkansas agency license and change the license
status to inactive. I am authorized to act on behalf of the above agency and have authority to make this request.
_______________________________________________
Dated: ____________________________
Signature of Authorized Agency Representative
_______________________________________________
Printed Name of Authorized Agency Representative
fFORM AID-LI-LS (Rev. 06-2021)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 Commerce Way, Ste 104
Little Rock, AR 72202
PHONE: 501-371-2750
Website:
https://insurance.arkansas.gov/pages/industry-regulation/licensing/
Email:
Insurance.Licensing@arkansas.gov
LICENSE SURRENDER FORM
INSTRUCTIONS: Completed/signed form may be scanned/emailed (address above). All areas of this form that
relate to the individual or the agency must be completed. If information does not apply, then mark the section N/A.
WE MUST HAVE A PHYSICAL ADDRESS FOR THE RESIDENCE. Use a separate form for each license type,
individual or agency – do not combine an individual and an agency on the same form. Combinations will not be
processed. This form must be completed in ink, typed, or computer generated. The form must be legible, or it will
not be processed. This form must be signed in order to be effective.
INDIVIDUAL:
Name: __________________________________________________________________________________
Arkansas License Number: __________________________________________________________________
License Type:___Producer___________________________________________________________________
Current Mailing Address: ____________________________________________________________________
Current Residence Address: ___________________________________________________________________
Street Number and Name
City
State
Zip
Please accept this as my request to voluntarily surrender my Arkansas producer license and change my license
status to inactive.
__________________________________________________
Dated: ______________________________
Licensee’s Signature
BUSINESS ENTITY (AGENCY):
Name: __________________________________________________________________________________
Arkansas License Number: _________________________________________________________________
Current Mailing Address: __________________________________________________________________
Current Physical Address: __________________________________________________________________
Street Number and Name
City
State
Zip
Please accept this as my request to voluntarily surrender the Arkansas agency license and change the license
status to inactive. I am authorized to act on behalf of the above agency and have authority to make this request.
_______________________________________________
Dated: ____________________________
Signature of Authorized Agency Representative
_______________________________________________
Printed Name of Authorized Agency Representative