Department of Consumer and Business Services




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Department of Consumer and Business Services

Insurance Division — 3


P.O. Box 14480, Salem, Oregon 97309-0405

Phone: 503-947-7981, Fax: 503-378-4351

350 Winter St. NE, Salem, Oregon

Email: web.insagent@oregon.gov



www.insurance.oregon.gov




Termination of Appointment Notice







Insurers must notify the director of DCBS of termination within 30 days of the effective date.

Please print or type

Name of agent/agency:

     

Oregon license number:

     

Agency address:

     

FEIN:

     

City, state, ZIP:

     

Name of appointing insurer:

     

Oregon certificate of authority number:

     

NAIC number:

     

Street address:

     

City, state, ZIP:

     

Date appointment terminated:

     

Date agent notified of termination:

     

1. Did you terminate this agent/agency appointment for any reason specified in ORS 744.081(2)(a)(c)(d)*?

 Yes  No

2. If the answer is yes, please attach a detailed explanation.

Officer or individual having power of attorney on file with the Department of Consumer and Business Services:




     




     

Print name




Title







     

Signature




Date




*ORS 744.081(2) Termination of appointment

“…The following are grounds for termination under this subsection:



  1. The agent’s insurance license is denied, restricted, revoked, suspended, or canceled by any public authority.

  1. The agent is insolvent or fails to remit balances to the insurer in accordance with the agreement.

  2. The agent commits fraud or engages in intentional misconduct.”




No fee required.

To receive confirmation of this termination,
a postage-paid return envelope is required.





440-3003 (8/15/COM)




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