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INSTRUCTIONS: CONNECTICUT LICENSE CANCEL/TERMINATION FORM

To request that a Connecticut license related to insurance be cancelled, use the form discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut License Cancel/Termination Form Step 1: Enter your Connecticut license number on the first blank line or your National Producer Number (NPN) on the second blank line.

Connecticut License Cancel/Termination Form Step 2: Enter the first, middle and last name of the licensee on the third blank line.

Connecticut License Cancel/Termination Form Step 3: Enter the last four digits of the Social Security number of the licensee on the fourth blank line.

Connecticut License Cancel/Termination Form Step 4: Enter the license type on the fifth blank line.

Connecticut License Cancel/Termination Form Step 5: Enter the name of the business entity on the sixth blank line.

Connecticut License Cancel/Termination Form Step 6: Enter the federal employer identification number of the business entity on the seventh blank line.

Connecticut License Cancel/Termination Form Step 7: Indicate with a check mark whether you wish for termination of this license to take place immediately or on the license expiration date.

Connecticut License Cancel/Termination Form Step 8: Write the reason for the requested termination where indicated.

Connecticut License Cancel/Termination Form Step 9: Question 1 requires you to indicate whether you currently have any complaints or actions which are pending, active or recently deposed filed against you by any state's insurance department by circling "yes" or "no." If yes, provide a written explanation.

Connecticut License Cancel/Termination Form Step 10: Question 2 requires you to indicate whether you currently have any complaints or actions which are pending, actively or recently deposed filed against you by the Financial Industry Regulatory Authority (FINRA) by circling "yes" or "no." If yes, provide a written explanation.

Connecticut License Cancel/Termination Form Step 11: Question 3 requires you to indicate whether any insurance company has terminated your appointment with them in the last 6 months by circling "yes" or "no." If yes, write the reason.

Connecticut License Cancel/Termination Form Step 12: Provide the name, phone number and email address of a contact person.

Connecticut License Cancel/Termination Form Step 13: The licensee should sign and date the form.