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Ohio Department of Insurance Agent / Agency Services

Online Agent Termination for Cause Form
  • Complete all required fields below. Required fields are marked with an *.
  • To print a blank form that you can complete by hand and mail.
  • Agent or Agency
    Name:*
    License Number:*
    Address 1:*
    Address 2:
    City:*

    State:*

    Zip:*

    Date of Birth:
    Lines of Authority:*
     
    Insurance Company 
    Name:*
    Address 1:*
    Address 2:
    City:*

    State:*

    Zip:*

    Telephone:*
    Fax:*
    FEIN:*
     
    Person Reporting 
    Name:*
    Telephone:*
     
     
    Reason for Termination:*
    Effective Termination Date:*
    Did the Agent's misconduct involve Ohio policy holders?*  Yes  No
    Description of Documentation to Support Termination:*
     
     

    The State of Ohio is an Equal Opportunity Employer

    50 W. Town Street, Third Floor - Suite 300   Columbus, Ohio   43215
    General Info: 614-644-2658  |  Consumer Hotline: 800-686-1526  |  Fraud Hotline: 800-686-1527  |  OSHIIP Hotline: 800-686-1578