Oid ok wp-contentuploadsLicense Surrender - Oklahoma Insurance Department 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. This is essential for record-keeping.
3. Fill in your TPA Licensee Name as shown on your Oklahoma license. Ensure clarity by typing or printing clearly.
4. Sign and provide your title if you are representing a Third Party Administrator entity.
5. Select one of the options regarding why you are surrendering your license. Be sure to check only one box.
6. Indicate whether you are attaching your original paper license, if it has been lost, or if you are providing documentation related to an individual’s death.
7. Complete your address, city, state, zip code, and contact phone number clearly.
8. Review all entries for accuracy before submitting the form via email or mail to the Oklahoma Insurance Department.

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