Ohio Department of Insurance Agent Termination For Cause Form

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Complete all sections below to report the termination of an agent for cause. Only one submission is necessary per agent.

* indicates a required field

Agent or Agency

Agent / Agency: *

Find Agent / Agency

Click this link to find a different agent or agency
Agent / Agency Name:
Address Line 1:
City, State, Postal Code:

Lines of Authority:

License #	License (Lines of Authority)	Status	Reason	Originally Issued	Effective Date	End/Expiration Date

Insurance Information

Name of Insurance Company Terminating Agent

Company Name:

Address I: *

City: *

State: *

Zip: *

Phone: *

FAX:

FEIN: *

Insurance Information

Additional Insurance Companies Subject To Termination

List All Companies And NAIC Number Subject To Appointment Termination: *

Insurance Information

Person Reporting

First Name *

Middle

Last Name *

Email Address: *

Phone Number: *
(XXX-XXX-XXXX)

Reason for Termination: *

Effective Termination Date: *

Did the Agent's misconduct involve Ohio policyholders?: *

Yes No

Description of Documentation to Support Termination: *

Insurance Information

Supporting Documents (OPTIONAL)

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Most image, document, audio and video file types are supported. Click here for a full list.

The following file types may be uploaded as attachments:

Document Files	Excel Files	Audio Files	Image/ Video Files
DOC	CSV	MP3	DIVX
DOCX	DIF	MPEG	FLV
HTML	XLS	WAV	MKV
HTM	XLSX	WMA	MOV
PDF	XLX		MPEG
RTF	XML		WMV
TXT	XPX		XVID
XPS

Click here to choose a file to upload.

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Contact Information

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AGENT / AGENCY SEARCH CRITERIA

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Search For:

Agency Name:

Last Name:

First Name:

Middle Name:

Agency City:

Residency:

License Type:

National Producer #:

Active Licenses Only


No matching agents found.


		Business Location:		Select Agent


No matching agencies found.

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Agent / Agency Name: *

License Number:

Address Line 1:

Address Line 2:

Agent Agency City:

State: Zip/Postal Code:

Email Address:

Phone Number:

Date of Birth:

Lines of Authority:

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Version: Release-3