Form L-198 - License Document Request - 2000 printable pdf download

INSURANCE LICENSING SECTION

2910 NORTH 44TH STREET, SUITE 210

PHOENIX, ARIZONA 85018-7256

LICENSE DOCUMENT REQUEST

ENTER THE FULL NAME OF THE LICENSEE (space provided for individual or firm)

Last Name

First Name

Middle Name

Full Name of the Business (if the “licensee” is a firm)

_____________________

AZ Insurance License No.

Is this a request for a DUPLICATE LICENSE CERTIFICATE?

1 1 No

1 1 Yes (include the fee of $1.25 as of 7/1/00)

NOTE: If “yes’, state the reason a duplicate license certificate is required._________________________________________

____________________________________________________________________________________________________

Is this a request for CERTIFICATION OF LICENSE STATUS?

1 1 No

1 1 Yes (how many)?_______ (include the fee of $2.50 for each as of 7/1/00)

NOTE: If “yes” and you wish the certification(s) mailed, please include a self-addressed, stamped envelope. If you wish to

pick up the certifications, please provide a telephone number and contact person whom we can call you when they are ready

____________________________________________

(________)________-_______________

Is this a request for a CLEARANCE LETTER?

1 1 No

1 1 Yes

NOTE: If “yes” why is the clearance letter requested? (if relocating to another state, please include the name):

____________________________________________________________________________________________________

Licensees must relinquish the original license certificate if it is still active. Also, if the license expired more than six

months ago, the file is in storage at another location and must be ordered. There is no charge. Allow three weeks for

processing. If you wish the clearance letter mailed, please include a self-addressed, stamped envelope. If you wish to pick

up the clearance letter, please provide a telephone number and contact person whom we can call you when it is ready.

____________________________________________

(________)________-_______________

____________________________________________

_____/_____/_____

Signature of Requestor*

Date

* If you are not the licensee, print your full name and indicate your relationship to the licensee below.

__________________________________________________

_____________________________________

Last Name

First

Middle

Relationship

Form L-198 (Eff.4/00)

Form L-198 - License Document Request - 2000

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