Cal. Code Regs. tit. 10 § 2548.26
State of California
Department of Insurance
Business Entity Endorsement Termination
LIC 411-8T (Rev 11/2014)
___________________________
Producer Licensing Bureau
P.O. Box 1139
Sacramento, CA 95812-1139
(916) 322-3555 or (800) 967-9331
Pursuant to Section 1627 and 1661 of the Insurance Code
License Number of Business Entity: ____________________
| Business Entity Name: |
| Mailing Address: |
| City, State, Zip: |
To the Insurance Commissioner of the State of California: Notice is hereby given that effective from the date of filing this notice, the Business Entity hereby terminates the endorsement of the person(s) named herein.
Note: Enter only one termination type per line. (Exception SL/SP)
*AH - Accident and Health Agent *LO - Life-Only Agent LI - Life-Limited to the Payment of Funeral & Burial Expenses FX - Fire/Casualty Broker-Agent AU - Limited Lines Automobile Insurance Agent LA - Life and Disability Analyst CS - Cargo Shipper's Agent **CI - Credit Insurance Agent PL - Personal Lines Broker Agent MC - Motor Club Agent SL - Surplus Line Broker SP - Special Lines' Surplus Line Broker SL/SP - Surplus Line and Special Lines' Surplus Line Broker ** LS - Life Settlement Broker
| Endorsement Type** | Endorsee's Social Security Number*** | Endorsee's Name (as shown on license) | Effective Date of Termination | |
| 1. | ||||
| 2. | ||||
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| 5. | ||||
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| 9. | ||||
| 10. |
Signature of an authorized representative
| ?? | Title: | Date: |
| Phone Number: () |
| Filing fee: Submit $26 per termination type. | Enter number of terminations: | X $26 |
Mail Termination form and fee to:
California Department of Insurance
P.O. Box 957
Sacramento, CA 95812-0957
* If endorsing both Accident and Health Agent and Life-Only Agent submit only one filing fee.
** There is no termination fee for the Credit Insurance Agent or the Life Settlement Broker.
***Disclosure of your U. S. social security number is mandatory pursuant to Cal. Civil Code, § 1798.17; Cal. Family Code, § 17520(d); and Federal Privacy Act of 1974, §§ 7(a) (2) (B) and 7(b). Your social security number will be used primarily for purposes of processing your application, including conducting any necessary investigation into your background. If you fail to disclose your social security number, your application will not be reviewed. An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone (800-967-9331) or by mail, to the following address: 320 Capitol Mall, Sacramento CA 95814.
Cal. Code Regs. Tit. 10, § 2548.26
2. Change without regulatory effect amending NOTE filed 1-24-2012 pursuant to section 100, title 1, California Code of Regulations (Register 2012, No. 4).
3. Renumbering of former section 2548.26 to section 2548.27 and renumbering and amendment of former section 2548.25 to new section 2548.26 filed 11-25-2014; operative 1-1-2015 (Register 2014, No. 48).
Note: Authority cited: Sections 10113.35 and 12978, Insurance Code; CalFarm Ins. Co. v. Deukmejian, 48 Cal.3d 805 (1989); 20th Century Ins. Co. v. Garamendi, 8 Cal.4th 216 (1994). Reference: Sections 10113.1 and 10113.2, Insurance Code.
2. Change without regulatory effect amending Note filed 1-24-2012 pursuant to section 100, title 1, California Code of Regulations (Register 2012, No. 4).
3. Renumbering of former section 2548.26 to section 2548.27 and renumbering and amendment of former section 2548.25 to new section 2548.26 filed 11-25-2014; operative 1/1/2015 (Register 2014, No. 48).