Agency Appointment/ Termination Request
If requesting Termination: Only Legal Agency Name, NPN, and Termination is needed.
Appointment or Termination:
Legal Agency Name (as shown on license):
FEIN
Agency Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Resident State
National Producer Number (NPN):
LOA/Type:
Falls Lake Program
FLI_External_Appointments@fallslakeins.com
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Please enter the state(s) to be appointed and provide the state license number (license not required if requesting termination):
Alabama license number
Alaska license number
Arizona license number
Arkansas license number
California license number
Colorado license number
Connecticut license number
Delaware license number
Washington D.C. license number
Florida license number
Georgia license number
Hawaii license number
Idaho license number
Illinois license number
Indiana license number
Iowa license number
Kansas license number
Kentucky license number
Louisiana license number
Maine license number
Maryland license number
Massachusetts license number
Michigan license number
Minnesota license number
Mississippi license number
Missouri license number
Montana license number
Nebraska license number
Nevada license number
New Hampshire license number
New Jersey license number
New Mexico license number
New York license number
North Carolina license number
North Dakota license number
Ohio license number
Oklahoma license number
Oregon license number
Pennsylvania license number
Puerto Rico license number
Rhode Island license number
South Carolina license number
South Dakota license number
Tennessee license number
Texas license number
Utah license number
Vermont license number
Virginia license number
Washington license number
West Virginia license number
Wisconsin license number
Wyoming license number
FLI_External_Appointments@fallslakeins.com
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