State of California Department of Insurance Action Notice of Appointment LIC 447-54A (Rev 3/1/2015) Pursuant to Sections 1704 through 1707 and/or 1756 of the Insurance Code Insurer Name: FEIN: NAIC # Federal Employer Identification Number To the Insurance Commissioner of the State of California: Notice is hereby given that effective from the date shown on this notice; the designated insurer hereby appoints the person(s) named herein to act as its agent. *Appoint Type: Only one appointment type per line. *AH - Accident and Health Agent; *LO - Life-Only Agent; LI - Life-Limited to the Payment of Funeral & Burial Expenses; *PR - Property Broker-Agent; *CA - Casualty Broker-Agent; AU - Limited Lines Auto 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; PF - Part Time Fraternal Agent; TA Limited Lines Travel Agent; DO - Disability Only; HP - Home Protection; VC Variable Contract Appoint Type ** National Producer Number (NPN) CA License # Name: As shown on license Effective date of Appointment 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Signature of Insurer: Signature must be that of an officer of the Company or a person authorized under a Special Power of Attorney on file with the Department. Name Official Title Date Phone Number ( ) E-mail Filing fee: Submit $29 filing fee per appointment type. Enter number of appointments: X $29 $ Please note: if you are appointing an applicant for an insurance license, submit only one name per form and attach the form to the application. If you are submitting only an action notice Mail Action Notice and fee to: California Department of Insurance, Box 928, Sacramento, CA 95812-0928. or * If Action Notice is being submitted with original application Mail Action Notice with Application and fee to: California Department of Insurance, Box 1139, Sacramento, CA 95812-1139 *If endorsing Accident and Health Agent, Life-Only Agent and Variable Contract Authority or Property Broker Agent and Casualty Broker-Agent submit only one filing fee. ** For Credit Insurance applicants only: submit $41 per endorsement.
State of California Department of Insurance Action …
State of California Department of Insurance Action Notice of Appointment LIC 447-54A (Rev 3/1/2015) Pursuant to Sections 1704 through 1707 and/or 1756 of the ...
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