"Request to Remove a Line of Authority" - New Hampshire

Request to Remove a Line of Authority is a legal document that was released by the New Hampshire Insurance Department - a government authority operating within New Hampshire.

Form Details:

  • The latest edition currently provided by the New Hampshire Insurance Department;
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  • Fill out the form in our online filing application.

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 to Remove a Line of Authority" - New Hampshire

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The State of New Hampshire
Insurance Department
21 South Fruit Street Ste 14
Concord NH 03301
(603) 271-0203 Fax (603)271-7029
TDD Access: Relay NH 1-800-735-2964
www.nh.gov/insurance
Christopher R. Nicolopoulos, Esq.
Alexander K. Feldvebel
Commissioner
Deputy Commissioner
Request to Remove a Line of Authority
Per RSA 400-a:29 The Department charges a $50 amendment fee to remove a line of authority or add
a line of authority from an existing license. The fee is per transaction not per line to be removed.
Lines of authority can be added directly online at
www.nipr.com
fee is also $50.
This form is NOT to be used to terminate the entire license. Please see the voluntary surrender form.
.
Name of the Individual or Entity:
NH License Number:
or
NPN:
Line(s) of Authority to REMOVE:
Signature of the Licensee or
Signature of the DRLP for the entity:
Mail form and amendment fee of $50, check made payable to the NH Insurance Department. Send to:
NH Insurance Department
21 South Fruit St Ste 14
Concord NH 03301
603-271-0203
The State of New Hampshire
Insurance Department
21 South Fruit Street Ste 14
Concord NH 03301
(603) 271-0203 Fax (603)271-7029
TDD Access: Relay NH 1-800-735-2964
www.nh.gov/insurance
Christopher R. Nicolopoulos, Esq.
Alexander K. Feldvebel
Commissioner
Deputy Commissioner
Request to Remove a Line of Authority
Per RSA 400-a:29 The Department charges a $50 amendment fee to remove a line of authority or add
a line of authority from an existing license. The fee is per transaction not per line to be removed.
Lines of authority can be added directly online at
www.nipr.com
fee is also $50.
This form is NOT to be used to terminate the entire license. Please see the voluntary surrender form.
.
Name of the Individual or Entity:
NH License Number:
or
NPN:
Line(s) of Authority to REMOVE:
Signature of the Licensee or
Signature of the DRLP for the entity:
Mail form and amendment fee of $50, check made payable to the NH Insurance Department. Send to:
NH Insurance Department
21 South Fruit St Ste 14
Concord NH 03301
603-271-0203