"Voluntary License Cancellation / Surrender" - Nebraska

Voluntary License Cancellation / Surrender is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

Form Details:

  • Released on June 1, 2020;
  • The latest edition currently provided by the Nebraska 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 Nebraska Department of Insurance.

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Download "Voluntary License Cancellation / Surrender" - Nebraska

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STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
LICENSING DIVISION
www.doi.nebraska.gov
Voluntary License Cancellation / Surrender
LICENSE INFORMATION
Last Name
License Number (NPN)
First Name
City
State
Zip
Mailing Address
Mailing Address
Phone
Email Address
___
Please cancel all of my Nebraska insurance licenses.
___
Please Only cancel my ________________________________________ license(s) and leave my
________________________________________ license(s) active in Nebraska.
*Indicate which Nebraska license type you wish to cancel and which you want to leave active.
AUTHORIZATION
In order to process the cancellation request the form must be signed by the Nebraska licensee.
_____________________________________________
________________________
Licensee’s Signature
Month/Day/Year
NEBRASKA DEPARTMENT OF INSURANCE
INSURANCE LICENSING DIVISION
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: doi.licensing@Nebraska.gov
Licensing Division: (402) 471-4913
DOI Main Line: (402) 471-2201
Toll Free: (833) 410-5609
Fax: (402) 471-4610
Rev. 6/20
DOI CANCEL
STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
LICENSING DIVISION
www.doi.nebraska.gov
Voluntary License Cancellation / Surrender
LICENSE INFORMATION
Last Name
License Number (NPN)
First Name
City
State
Zip
Mailing Address
Mailing Address
Phone
Email Address
___
Please cancel all of my Nebraska insurance licenses.
___
Please Only cancel my ________________________________________ license(s) and leave my
________________________________________ license(s) active in Nebraska.
*Indicate which Nebraska license type you wish to cancel and which you want to leave active.
AUTHORIZATION
In order to process the cancellation request the form must be signed by the Nebraska licensee.
_____________________________________________
________________________
Licensee’s Signature
Month/Day/Year
NEBRASKA DEPARTMENT OF INSURANCE
INSURANCE LICENSING DIVISION
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: doi.licensing@Nebraska.gov
Licensing Division: (402) 471-4913
DOI Main Line: (402) 471-2201
Toll Free: (833) 410-5609
Fax: (402) 471-4610
Rev. 6/20
DOI CANCEL