Insurance & Surety Company Termination "FOR CAUSE" Notice (Individual & Business Entity)

*As per CGS Sections: 38a-708, 38a-712, 38a-784, Insurance Companies are required to notify the Department of appointment terminations. This form should be completed for appointment terminations “FOR CAUSE” only. Standard administrative terminations for issues such as lack of production or change in employment should not use this form.

Instructions:

• Form MUST be submitted to the Department within 30 days of termination. CGS 38A-784a(d).
• A copy of the form MUST be sent to the producer within 30 days of termination. CGS 38A-784a(d).
• Keep copies for record.
• NOTICE: A compliance point of contact is REQUIRED; please provide contact information below.

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1. The Insurance or Surety Company indicated herein respectfully requests that you cancel the appointment for the individual or business entity named herein to act as an agent for this company. Effective Date As Of:      * Required
   
   
2. Has termination been reported to OTHER states or agencies?

   NO

   YES

   * Required
   If YES - Name of Agency:  
   
   Date Reported:     
   
   
3. Were any Connecticut consumers affected?

   NO

   YES

   * Required
   NOTE: NAMES AND ALL RELEVANT FILE DOCUMENTS FOR AFFECTED CONNECTICUT CONSUMERS MUST BE FORWARDED TO DEPT.
   Send via email or fax to: cid.fraud@ct.gov OR FAX 860-297-3872
   
   
4. Reason for termination: (check all that apply)

   Failure to Remit

   Falsifying Documents

   Misrepresentation

   Other

   
   Explanation:   
   
   

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* NOTICE: A compliance point of contact is REQUIRED in case additional information is necessary.

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