Form AID-LI-MGA42 "Termination of Company Appointment of Managing General Agent" - Arkansas

What Is Form AID-LI-MGA42?

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-MGA42 by clicking the link below or browse more documents and templates provided by the Arkansas Insurance Department.

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FORM AID-LI-MGA42 (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750
FAX: 501-683-2604
TERMINATION OF COMPANY APPOINTMENT
OF MANAGING GENERAL AGENT
1. Name of the MGA_____________________________________________________
2. FEIN # of the MGA _______________________________________________
3. Name of the Insurance Company ______________________________________________
4. Insurance Company NAIC # _______________________
5. Insurance Company Contact Person:
________________________________________________________
Name
________________________________________________________
Phone Number
To the Insurance Commissioner of the State of Arkansas:
It is the intent of the Insurance Company to terminate the appointment of this Managing General Agent.
The undersigned as an authorized representative of the Insurance Company hereby terminates the
association of the insurance company with the above listed Managing General Agent.
Date __________________________________________
_______________________________________
Signature
__________________________________________________________
Typed or Printed Name
__________________________________________________________
Title
FORM AID-LI-MGA42 (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750
FAX: 501-683-2604
TERMINATION OF COMPANY APPOINTMENT
OF MANAGING GENERAL AGENT
1. Name of the MGA_____________________________________________________
2. FEIN # of the MGA _______________________________________________
3. Name of the Insurance Company ______________________________________________
4. Insurance Company NAIC # _______________________
5. Insurance Company Contact Person:
________________________________________________________
Name
________________________________________________________
Phone Number
To the Insurance Commissioner of the State of Arkansas:
It is the intent of the Insurance Company to terminate the appointment of this Managing General Agent.
The undersigned as an authorized representative of the Insurance Company hereby terminates the
association of the insurance company with the above listed Managing General Agent.
Date __________________________________________
_______________________________________
Signature
__________________________________________________________
Typed or Printed Name
__________________________________________________________
Title