Connecticut Insurance Department
Insurance & Surety Company Termination "FOR CAUSE" Notice (Individual & Business Entity)

*As per CGS Sections: 38a-708, 38a-712, 38a-784, Insurance Companies are required to notify the Department of appointment terminations. This form should be completed for appointment terminations “FOR CAUSE” only. Standard administrative terminations for issues such as lack of production or change in employment should not use this form.

Instructions:

  • Form MUST be submitted to the Department within 30 days of termination. CGS 38A-784a(d).
  • A copy of the form MUST be sent to the producer within 30 days of termination. CGS 38A-784a(d).
  • Keep copies for record.
  • NOTICE: A compliance point of contact is REQUIRED; please provide contact information below.

Name of Insurance or Surety Company:  
NAIC Number:  
Licensee’s Full Legal Name:  
License Number:  
Licensee’s Resident Address (Street/City/State /Zip Code):  
  1. The Insurance or Surety Company indicated herein respectfully requests that you cancel the appointment for the individual or business entity named herein to act as an agent for this company. Effective Date As Of:       

  2. Has termination been reported to OTHER states or agencies?  
    If YES - Name of Agency:  
    Date Reported:     

  3. Were any Connecticut consumers affected?  
    NOTE: NAMES AND ALL RELEVANT FILE DOCUMENTS FOR AFFECTED CONNECTICUT CONSUMERS MUST BE FORWARDED TO DEPT.
    Send via email or fax to: cid.fraud@ct.gov OR FAX 860-297-3872

  4. Reason for termination: (check all that apply)



    Explanation:   


* NOTICE: A compliance point of contact is REQUIRED in case additional information is necessary.

Name of Authorized Company Compliance Contact:  
Title:  
Phone Number:  
Email Address:  

Name of person submitting form:  
Submitter’s Email Address:  
  (A confirmation will be sent to this email address)
CONFIRM submitters email address:  
Submitter’s Phone:  
Submit Date: