Insurance Agent/Agency Order Form - Texas Department of Insurance

Insurance Agent/Agency Order Form - Texas Department of Insurance

1 Pages · 2010 · 160 KB · English

FEE Total $ With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collec Texas Department of Insurance

Insurance Agent/Agency Order Form - Texas Department of Insurance free download


Texas Department of Insurance Publication Distribution, Mail Code 9999 MC 9999, P. O. Box 149104, Austin, Texas 78714-9104 512-322-4283 telephone • 512-305-7512 fax • www.tdi.state.tx.us Insurance Agent/Agency Order Form Agent/Agency Data available on CD only and includes: Original State ID Number, License ID Number, Name, Address, City, State, ZIP, Phone, License Type, Qualification Type, License Issue Date, License Expiration Date Indicate quantity by each license type. Cost is $15.00 per license type, per CD. Listings are available for download on the Texas Department of Insurance website at http://www.tdi.state.tx.us/licensing/agent/agentlists.html . ______ County Mutual Agent/Agency ______ Reinsurance Broker Agent/Agency ______ Emergency Managing General Agent ______ Reinsurance Manager Agent/Agency ______ General Line Agent/Agency ______ Risk Manager Agent ______ Insurance Adjuster ______ Specialty Insurance Agent/Agency ______ Insurance Service Representative ______ Surplus Lines Agent/Agency ______ Life Insurance Not to Exceed ______ Temporary County Mutual Agent $25,000 Agent/Agency ______ Temporary General Lines Property ______ Life and Health Insurance Counselors and Casualty Agent Individual/Agency ______ Temporary General Lines Life Accident ______ Limited Lines Agent/Agency and Health Agent ______ Managing General Agent/Agency ______ Temporary Life Agent ______ Pre-Need Agent/Agency ______ Temporary Limited Lines Agent ______ Public Insurance Adjuster Individual/Firm ______ Temporary Pre-Need Agent ______ Public Insurance Adjuster Trainee ______ Trainee Adjuster Insurance Company Agent Appointment Order Form Company Appointments of Agents (Please specify exact company name) Includes Old TDI Number, Individual ID Number, Name, Address, City, State, ZIP, Phone, License Type, Quali fication Type, License Issue Date, License Expiration Date, Appointment Effective Date, Appointment Type, NAIC Number, Appointment Company Name Complete the information below and indicate order quantity in the space by your preferred format (CD or e-mail). COMPANY NAME NAIC# COMPANY # ______ CD @ $15.00

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