Get Mi Fis 0261 2015-2025

FIS 0261 5/15 Department of Insurance and Financial Services Page 1 of 1 Insurance License Document Request In lieu of submitting this form to document licensure companies should make a screen print of the producer s license status from the DIFS Insurance Agent Locator or Insurance Agency Locator or from the NAIC Producer Database. Use a separate form for each licensee. There is no charge for these documents. Please do not send money with this form* Required Information about the licensee First Name Middle initial / name System ID Michigan License Number Suffix Jr Sr I II etc* Full Employer ID number business entity OR Last 4 digits of your Social Security Number Document s you are requesting Licensing History Current status is available on the DIFS Insurance Agent Locator or Insurance Agency Locator Address on file for the licensee if shipment to another address is needed provide address below Check to request a License History Document Certification Letter Most states rely on the NAIC Producer Database to verify Name license status. A Certification Letter may only be requested for Bail Bonds Producer Address Line 1 Surplus Lines Non-Resident licensure Third Party Administrator City Duplicate License / Certificate of Authority are automatically sent to the licensee s Mailing Address in the DIFS database. Check appropriate box below to indicate type of Duplicate License you are requesting Producer Individual or Agency Solicitor Counselor Insurance Adjuster Adjuster for the Insured State/Province ZIP/Postal Code Country Clearance Letter for individual licensees only To receive a Clearance Request Enter your mailing address in your new state below AND attach your original license to this form* If you no longer possess an original license to return read and initial the lost or destroyed affidavit below. Affidavit of lost or destroyed license document I swear under penalty of perjury that the license granted to me or the agency/entity named on this document request is no longer in my possession and as such cannot be returned* Should I find the license at a later date I agree to immediately destroy it. Initial here if you agree with the above statement I certify that the information given on and attached to this form is complete and correct. Signer s name typed or printed Signer s title typed or printed Signature Date signed When complete please send this form and any attachments to DIFS Insurance Licensing P. O. Box 30220 Lansing MI 48909-7720 or Fax to 517 284-8836 Authority PA 218 of 1956 as amended* Submission is required to report changes to an insurance licensee s name mailing address changes and other information* Failure to file may result in an action against license s held including a monetary fine and/or license suspension or revocation*. Use a separate form for each licensee. There is no charge for these documents. Please do not send money with this form* Required Information about the licensee First Name Middle initial / name System ID Michigan License Number Suffix Jr Sr I II etc* Full Employer ID number business entity OR Last 4 digits of your Social Security Number Document s you are requesting Licensing History Current status is available on the DIFS Insurance Agent Locator or Insurance Agency Locator Address on file for the licensee if shipment to another address is needed provide address below Check to request a License History Document Certification Letter Most states rely on the NAIC Producer Database to verify Name license status. A Certification Letter may only be requested for Bail Bonds Producer Address Line 1 Surplus Lines Non-Resident licensure Third Party Administrator City Duplicate License / Certificate of Authority are automatically sent to the licensee s Mailing Address in the DIFS database. .