Appointment termination: Fill out & sign online

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Click ‘Get Form’ to open the appointment termination form in the editor.
Begin by entering the appointee information, including the agent or agency name as it appears on the TDI license and the TDI license number.
Next, provide the insurer information. Fill in the name of the insurance company (note that group names are not acceptable) and include the NAIC or Federal tax ID number.
Select all applicable boxes to indicate the type of appointment being terminated. This includes various license types such as General Lines Life, Accident, and Health, among others.
Indicate the relevant statute by selecting from the provided options to ensure compliance with regulations.
Complete the attestation section by confirming that you have attached a statement detailing the facts related to termination, including date and cause.
Finally, fill in your email address, mailing address, city, state, ZIP code, print your name, date, and provide your signature before submitting.

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