"Request Form to Surrender, Terminate or Cancel a License" - New Hampshire

Request Form to Surrender, Terminate or Cancel a License is a legal document that was released by the New Hampshire Insurance Department - a government authority operating within New Hampshire.

Form Details:

  • Released on September 1, 2018;
  • The latest edition currently provided by the New Hampshire Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

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

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Download "Request Form to Surrender, Terminate or Cancel a License" - New Hampshire

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The State of New Hampshire
Insurance Department
21 South Fruit Street
Suite 14
Concord, NH 03301
(603) 271-2261 Fax (603) 271-7029
TDD Access: Relay NH 1-800-735-2964
REQUEST FOR CANCELLATION OF LICENSE
PRODUCER, ADJUSTER, PUBLIC ADJUSTER
Uses: This form is to be completed by NH Insurance Department Licensees who wish to
terminate, surrender, or cancel their license prior to its expiration date.
Instructions: Complete and sign this form. Submit this form by any one of these three
methods:
PREFERRED METHOD
Attached to e-mail at
producerquestions@ins.nh.gov
USPS mail to:
New Hampshire Insurance Department
Attn: Producer Licensing
21 South Fruit Street
Suite 14
Concord, NH 03301
Fax transmission to:
(603) 271-7029
Typed or printed name_________________________________________________________________
NH Producer or Adjuster license number _______________________________________________
I am requesting that my license as indicated above be cancelled as I wish to voluntarily
surrender my license. I certify that I am the licensee to whom this license was issued.
I understand that voluntary cancellation does not release me from the results of any pending or
future administrative actions, including orders revoking or suspending my license privileges,
fines imposed, or other penalties imposed due to my conduct as a producer adjuster during the
time I held a valid license.
If terminating an entity license, either DRLP or officer of the entity must sign & state title.
________________________________
________________________________
(signature)
(date)
For those that are terminating their resident license in NH because of move out of state and want to maintain a NonResident license
in NH: Per RSA 402J:7 VI you have 30 days to obtain a resident license in your new resident state and notify us of your address
change with the form on our website. Your license will be reactivated as a non-resident at no additional fee above the address change
fee of $10.
Revision 9/1/2018
The State of New Hampshire
Insurance Department
21 South Fruit Street
Suite 14
Concord, NH 03301
(603) 271-2261 Fax (603) 271-7029
TDD Access: Relay NH 1-800-735-2964
REQUEST FOR CANCELLATION OF LICENSE
PRODUCER, ADJUSTER, PUBLIC ADJUSTER
Uses: This form is to be completed by NH Insurance Department Licensees who wish to
terminate, surrender, or cancel their license prior to its expiration date.
Instructions: Complete and sign this form. Submit this form by any one of these three
methods:
PREFERRED METHOD
Attached to e-mail at
producerquestions@ins.nh.gov
USPS mail to:
New Hampshire Insurance Department
Attn: Producer Licensing
21 South Fruit Street
Suite 14
Concord, NH 03301
Fax transmission to:
(603) 271-7029
Typed or printed name_________________________________________________________________
NH Producer or Adjuster license number _______________________________________________
I am requesting that my license as indicated above be cancelled as I wish to voluntarily
surrender my license. I certify that I am the licensee to whom this license was issued.
I understand that voluntary cancellation does not release me from the results of any pending or
future administrative actions, including orders revoking or suspending my license privileges,
fines imposed, or other penalties imposed due to my conduct as a producer adjuster during the
time I held a valid license.
If terminating an entity license, either DRLP or officer of the entity must sign & state title.
________________________________
________________________________
(signature)
(date)
For those that are terminating their resident license in NH because of move out of state and want to maintain a NonResident license
in NH: Per RSA 402J:7 VI you have 30 days to obtain a resident license in your new resident state and notify us of your address
change with the form on our website. Your license will be reactivated as a non-resident at no additional fee above the address change
fee of $10.
Revision 9/1/2018