Forms for Insurance Licensing

Title Description
Form AC (03/24/2017) Notice of Address Change for Hawaii Insurance Division licensees and registrants only
Form ADR (08/23/2013) Adding a Designated Representative from the Business Entity’s License
Form APPT (8/20/2013) Notice of New Appointment
Form APPTMGA (8/23/2011) Notice of New MGA Appointment
Form ARC Adding / Removing Classes of Insurance from a Hawaii Insurance License
Form BEPL (06/2015) Hawaii Application for Business Entity Insurance License / Registration
Form CN & FBI PAS (07/2016) State and National Criminal History Record Check Consent & Notification
Form DLC (9/16/2009) Request for Duplicate License
Form FRS (Revised 01/12/2016) Service Contract Provider’s Financial Responsibility Statement
Form HPL (07/2016) Hawaii Application for Individual Insurance License
Form LC (06/02/2009) Request for Letter of Certification / Letter of Clearance
Form LSB LSP Hawaii Application for Individual or Legal Entity – Life Settlement Broker or Provider Insurance License
Form NTA (01/26/2017) Notice of Name Change – Adding/Removing Trade Name – Adding Assumed Name
Form PBM (06/26/2017) Pharmacy Benefit manager Application / Renewal
Form RDR (08/23/2013) Removing a Designated Representative from the Business Entity’s License
Form SCP (03/2008) Service Contract Provider Registration Form
Form T (9/10/2009) Notice of Termination of Appointment
Form VPPW (03/2008) Vehicle Protection Product Warrantor Registration Form
Form VS (05/29/2009) Voluntary Surrender of License