Maryland insurance administration service request form 2025

1. Click ‘Get Form’ to open the Maryland Insurance Administration Service Request Form in our editor.
2. Begin by selecting the 'Request Type' from the options provided, such as Name Change or License Cancellation. Clearly specify your choice.
3. In the 'Licensee Information' section, enter your full name and Maryland license number. If applicable, include your National Producer Number (NPN) and select your license type from the list.
4. If you are requesting a name change, provide both your current and new names. Attach any required documentation for verification, such as a marriage certificate or court order.
5. For license cancellation requests, indicate the reason for cancellation in the designated field. Remember that this action will result in your license being cancelled without notification.
6. If modifying lines of authority, specify which lines you wish to add or cancel in the appropriate section.
7. Complete the 'Trade Name Registration' if you wish to operate under a different name than listed on your license. Provide the requested trade name.
8. Finally, ensure that an authorized requester signs and dates the form before submission. Include their printed name and contact information.

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