"Individual Voluntary Surrender Form" - Mississippi

Individual Voluntary Surrender Form is a legal document that was released by the Mississippi Department of Insurance - a government authority operating within Mississippi.

Form Details:

  • Released on July 1, 2015;
  • The latest edition currently provided by the Mississippi Department of Insurance;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Department of Insurance.

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Download "Individual Voluntary Surrender Form" - Mississippi

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Mike Chaney
501 N. West St., Suite 1001
Woolfolk State Office Building
Commissioner of Insurance
Jackson, MS 39201
P.O. Box 79
Jackson, MS 39205
STATE OF MISSISSIPPI
Mississippi Insurance Department
www.mid.ms.gov
Individual Voluntary Surrender Form
 Resident
Non-Resident
INSTRUCTIONS: All areas of this form that relate to the individual (producer/adjuster) must be
complete. WE MUST HAVE A PHYSICAL ADDRESS FOR THE RESIDENCE. Use a separate form
for each license type. The form must be legible or it will not be processed. This form may be faxed @
601-359-1951, scanned and emailed to licensing@mid.ms.gov, or mailed to Mississippi Insurance
Department, P. O. Box 79, Jackson, Mississippi 39205.
No Fee: $0.00
INDIVIDUAL: PRODUCER/ADJUSTER
Current Name (Please print name as it appears on MS license) _______________________________
MS license # ______________________________ NPN# ___________________________________
License Type _______________________________________________________________________
Reason for surrendering: ____________________________________________________________
_________________________________________________________________________________
Current Mailing Address: ____________________________________________________________
Current Residence Address: __________________________________________________________
Please accept this as my request to voluntarily surrender my Mississippi producer/adjuster license. I
understand I am no longer authorized to transact insurance under the license stated above.
Print name of Licensee ______________________________________________________________
Signature of Licensee _______________________________________ Date __________________
7/2015
Print Form
Clear Form
Mike Chaney
501 N. West St., Suite 1001
Woolfolk State Office Building
Commissioner of Insurance
Jackson, MS 39201
P.O. Box 79
Jackson, MS 39205
STATE OF MISSISSIPPI
Mississippi Insurance Department
www.mid.ms.gov
Individual Voluntary Surrender Form
 Resident
Non-Resident
INSTRUCTIONS: All areas of this form that relate to the individual (producer/adjuster) must be
complete. WE MUST HAVE A PHYSICAL ADDRESS FOR THE RESIDENCE. Use a separate form
for each license type. The form must be legible or it will not be processed. This form may be faxed @
601-359-1951, scanned and emailed to licensing@mid.ms.gov, or mailed to Mississippi Insurance
Department, P. O. Box 79, Jackson, Mississippi 39205.
No Fee: $0.00
INDIVIDUAL: PRODUCER/ADJUSTER
Current Name (Please print name as it appears on MS license) _______________________________
MS license # ______________________________ NPN# ___________________________________
License Type _______________________________________________________________________
Reason for surrendering: ____________________________________________________________
_________________________________________________________________________________
Current Mailing Address: ____________________________________________________________
Current Residence Address: __________________________________________________________
Please accept this as my request to voluntarily surrender my Mississippi producer/adjuster license. I
understand I am no longer authorized to transact insurance under the license stated above.
Print name of Licensee ______________________________________________________________
Signature of Licensee _______________________________________ Date __________________
7/2015
Print Form
Clear Form