KENNY C - Nevada Division of Insurance



VOLUNTARY SURRENDER OF LICENSE

Licensees may utilize this form to notify the Nevada Division of Insurance (“Division”) of the licensee’s intention to voluntary surrender a Nevada license, effective immediately.

Pursuant to (“NRS”) 679A.190, the expiration or voluntary surrender of a license or certificate issued pursuant to the provisions of this Code does not:

      1.  Prohibit the Commissioner from initiating or continuing a disciplinary proceeding against the holder of the license or certificate; or

      2.  Prevent the imposition or collection of any fine or penalty authorized pursuant to the provisions of this Code against the holder of the license or certificate.

Surplus Lines Brokers must contact the Nevada Surplus Lines Association as well as the Division’s Corporate and Financial Affairs Section to determine if there are any deficiencies in the broker’s Quarterly or Annual Surplus Lines Broker Statement Filing Reports. Business entities must contact the Nevada Secretary of State’s Office to determine the appropriate steps to withdraw the entity’s qualification to do business in this state.

Name: ________________________________________________________________________

Nevada License Number: ________________________________________________________

FEIN/SSN/NPN: _______________________________________________________________

Upon receipt of the request to voluntarily surrender a license, the Division will inactivate the license, affiliation(s), and all appointments held by a licensee in this state. Pursuant to Nevada Revised Statute NRS 683A.480, the licensee must surrender its license to the Commissioner.

Licenses are being returned

Licenses are being destroyed

Licenses are misplaced and will be destroyed if found

Licensee’s Signature: _____________________________________ Date: _____________

NDOI 237 DOC 323B Voluntary Surrender of License (rev 2.01.12)

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Department of Business and Industry

Nevada Division of Insurance

1818 E. College Pkwy, Suite 103, Carson City, Nevada 89706 Phone: (775) 687-0700 Fax: (775) 687-0797 Web: doi.

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