License Surrender And Letter Of Clearance - Louisiana Department Of Insurance
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1Louisiana Department of Insurance
License Surrender and Letter of Clearance
Submit via fax to (225) 342-3754 or by e-mail to
producer licensing@ldi.la.gov
LICENSEE INFORMATION
Producer
Adjuster
Resident
Nonresident
Name
Louisiana License Number
NPN( if known)
Contact Number
(
)
Business email
Personal email
REQUEST TO SURRENDER LICENSE
I am requesting the cancellation of my Louisiana insurance license.
_______________________________________________ ___________________________
Signature of Licensee
Date
_______________________________________________
Title of signer, if licensee is a business entity
REQUEST FOR LETTER OF CLEARANCE
I am requesting the issuance of a letter of clearance. I am a Louisiana resident and am moving to
another state. I am aware that the issuance of a letter of clearance will cancel my resident license in
the state of Louisiana. I understand that I may have my license re-activated as a nonresident by
submitting a written request within 30 days of the date my resident license was cancelled along with
evidence that I have become licensed as a resident in my new home state. I understand that after 30
days, I would need submit a nonresident application and fees to become relicensed.
Send clearance letter via e-mail to the following address________________________________
________________________________________________________
Mail hard copy to
___________________________________________________________________________
_______________________________________________ ___________________________
Signature of Licensee
Date
Cancel/LCLEAR
Rev. May 2016
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