MARYLAND INSURANCE ADMINISTRATION
SERVICE REQUEST FORM
DO NOT REMIT ANY PAYMENT WITH THIS REQUEST(S). Requests will be processed at no charge.
Submit forms to producerlicensing.mia@maryland.gov
or fax to (410) 468-2399. Maryland Insurance Administration 200 Saint Paul Place, Suite 2700, Baltimore, MD 21202
1.REQUEST TYPE
REQUEST TYPE (PLEASE SPECIFY BELOW)
Name Change
Line of Authority Modification
Trade Name Registration
Clearance / License Cancellation
2.LICENSEE INFORMATION
FULL NAME (Individual –or – Business Entity): _____________________________________________________________________________________________________
MARYLAND LICENSE NUMBER: ______________________________NATIONAL PRODUCER NUMBER (NPN) _________________________________________
LICENSE TYPE (PLEASE SPECIFY BELOW)
ADVISER
SELF-STORAGE SERVICE PRODUCER
MOTOR CLUB REPRESENTATIVE
SURPLUS LINES BROKER
MOTOR VEHICLE RENTAL COMPANY / FRANCHISEE
TEMPORARY PRODUCER
PORTABLE ELECTRONICS INSURANCE
THIRD PARTY ADMINISTRATOR
PRODUCER
THIRD PARTY ADMINISTRATOR (ERISA ONLY)
PUBLIC ADJUSTER
VIATICAL SETTLEMENT BROKER / PROVIDER
3. NAME CHANGE )
If individual name change is the result of a marriage, divorce, or court order, attach a copy of a marriage certificate, divorce decree, certificate from the clerk of the court,
or other official documentation indicating a formal name change. *NOTE: Copies of driver’s licenses and/or social security cards are not acceptable.
If name change is for a business entity attach confirmation that the name change has been registered with the State of Maryland Department of Assessment and Taxation.
CURRENT NAME
NEW NAME
4. LICENSE CANCELLATION )
Any request for a License Cancellation / Clearance will result in the license(s) being cancelled. You will not receive notification that this request has been processed. An
update to your state of Maryland license record will be reflected on the National Producer Database.
5. LINE OF AUTHORITY MODIFICATION (ADDITIONS / CANCELLATIONS) )
If you are interested in adding or cancelling line(s) of authority associated with a particular license class please identify which line(s) of authority you are interested in
adding or cancelling. You will not receive notification that this request has been processed. An update to your state of Maryland license record will be reflected on the
National Producer Database. To add the variable life & annuity line of authority to your license, please provide your active FINRA registration CRD number.
6. TRADE NAME REGISTRATION T
This field should be completed by individuals or entities wishing to do business under a name that is different from the name that appears on their Maryland license. Please list trade
name(s) below.
TRADE NAME REQUESTED
7. AUTHORIZED REQUESTER INFORMATION N
Signature of Authorized Requester: _______________________________________________________________ Date: _____________________________________________
Print Full Name: ______________________________________________________________________________ Title: _____________________________________________
Daytime Phone Number: _________________________________________________________________________ Fax: _____________________________________________
ADDITION
CANCELLATION
SPECIFY LINE(S) OF AUTHORITY TO BE ADDED or CANCELLED BELOW:
LIFE
TITLE
HEALTH
CREDIT PRODUCTS
PROPERTY
TRAVEL
CASUALTY
ADVISER LIFE/HEALTH
PERSONAL LINES
ADVISER PROPERTY/CASUALTY
VARIABLE LIFE & ANNUITY, CRD#
ADVISER VARIABLE
OTHER (MUST SPECIFY)____________________________________________________________