Fillable Form L-198 - License Document Request

INSURANCE LICENSING SECTION

2910 NORTH 44TH STREET, 2ND FLOOR • PHOENIX, ARIZONA 85018-7256 • PHONE: 602-912-8470 • FAX: 602-912-8473

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 REPLACEMENT LICENSE CERTIFICATE?

Yes (include the fee of $3.00)

If “yes”, your original License Certificate must accompany this request (if not available, note in statement below).

NOTE: If “yes”, describe why a replacement certificate is

required._______________________________________________

___________________________________________________________________________________________________

Is this a request for CERTIFICATION OF LICENSE STATUS?

Yes (how many)?_______ (include the fee of $3.00 for each)

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

pick up the certification(s), please provide a telephone number and contact person whom we can call you when they are

ready.

____________________________________________

(________)________-_______________

Printed Contact Person

Telephone Number

Is this a request for CLEARANCE LETTER?

Yes

(include the fee of $3.00)

NOTE: If “yes” Original License along with a self-addressed, stamped envelope must accompany this request.

Only the licensee (or if a business entity, an officer, member or director) may request a clearance letter. Please allow two

weeks for processing.

I am relocating to ___________________________________

Check one of the following two options (or

if not applicable)

I am surrendering my Arizona license and do not intend to be licensed in Arizona as a non-resident.

A licensee who surrenders an Arizona license must relinquish the original license certificate if the license has

not expired. A person who surrenders license authority is not permitted to reapply for the same authority for

at least six months after the date of surrender. [A.R.S. § 20-289(F)].

I am surrendering my Arizona license. I do intend to be licensed in Arizona as a non-resident.

Although you must pay for the clearance letter, no fee or application is required for you to change from being a

resident licensee to a non-resident licensee in Arizona [A.R.S. § 20-287(B)]. Instructions for obtaining a

clearance letter when relocating to another state are provided on the reverse.

____________________________________________

_____/_____/_____

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. 07/02)

Form L-198 - License Document Request - 2002

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