REQUEST FOR LETTER OF CLEARANCE & CERTIFICATION
[Pages:1]REQUEST FOR LETTER OF CLEARANCE & CERTIFICATION
Agent Licensing & Education
Agent's Name: ____________________________WV Lic/NPN #:__________
The Following is requested for the above named:
Letter of Certification A Letter of Certification is issued to an actively licensed resident agent who is applying for a non-resident license in another state.
Please issue certification of my WEST VIRGINIA Resident Agent's license as I am applying for nonresident licensing in another state. I am enclosing a self-addressed return envelope.
# Letters requested ___________ $5.00 per letter = $ ___________ Amount Due Check # ____________________ Date of Check _______________ I am an adjuster requesting the Letter of Certification include my Designated Home State
( Please check box above, if applicable).
Letter of Clearance A Letter of Clearance is issued for a WV resident agent who is or has moved to another state and is applying for a resident license in their new home state.
The licensee is the only party authorized to request cancellation of his/her license.
I have moved from WEST VIRGINIA to the State of
. Please CANCEL my West
Virginia license and forward a Letter of Clearance in the return envelope I have provided. I understand
that the insurance companies I represent will be notified that my license is being cancelled.
# Letters requested ___________ Check # ____________________
$10.00 per letter = $ _________ Amount Due Date of Check _______________
Return Address: ____________________________________________
____________________________________________
____________________________________________
Email or fax copy to: ____________________________________________
______________________________
_______________
Signature*
Date
*Request for Letter of Clearance must be signed by the agent
________________ Telephone
Remit Personal check, business check, cashier's check, or money order, payable to the WV Insurance Department to the address below.
Please include a self-addressed, postpaid envelope.
WV Insurance Commission ? 900 Pennsylvania Ave. 7th Fl - Charleston, WV 25302 P.O. Box 50541 - Charleston, WV 25305-0541 Email: OICagentlicensing@ Phone: 304-558-0610 Fax: 304-558-4966
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