LIC-050 Surplus Line and or Special: Fill out & sign online

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Click ‘Get Form’ to open the LIC-050 Surplus Line and or Special in the editor.
Begin by entering the Business Entity Name and License Number in the designated fields. Ensure that these details match your official documents.
Fill in the Mailing Address accurately, as this will be used for correspondence with the California Department of Insurance.
Select the appropriate Endorsement Type from the list provided. Remember, you can only enter one endorsement type per line unless it’s SL/SP.
Input the Endorsee’s Social Security Number and Name as shown on their license. This information is mandatory for processing.
Specify the Effective Date of Endorsement for each entry you make. This is crucial for record keeping.
Complete any additional endorsements by repeating steps 4 to 6 as necessary, up to ten endorsements.
Finally, ensure that an authorized representative signs and dates the form, providing their title and email address.

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