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Bureau of Insurance

Downloadable Forms

Service Request Form Form Name
Change Name
Correct SSN or FEIN
Trade Name Notification
Clearance Letter (moving out of Virginia)
Change of Address (used by non-resident agents only moving from one state to another)
Form 5001
Request for Agency License Withdrawal/Termination Agency Withdrawal
Request for List of Resident Agents for Continuing Education Mailings Guidelines and Form


Lines of Authority - Full Lines Form Name
Life & Annuities
Variable Contract
Health
Personal Lines
Property & Casualty
Title
Title Instructor Certification and
Affidavit of Course Completion
Form 3001






Certification and Affidavit

Lines of Authority - Limited Lines Form Name
Limited Lines Credit
Limited Lines Life & Health
Limited Lines Property & Casualty
Motor Vehicle Rental Contract
Form 3001




Lines of Authority - Temporary Form Name
Temporary Life & Health
Temporary Life & Health (Debit Only)
Temporary Property & Casualty
Form 3001



Lines of Authority - Non-Standard Form Name
Consultant (Life & Health)
Consultant (Property & Casualty)
Viatical Settlement Broker
Form 3001 (initial)



Surplus Lines Broker
Form 3001 (initial)
SLB-2
Lines of Authority - Business Entity (Agency) Form Name
Life & Annuities
Variable Contracts
Health
Property & Casualty
Title
Form 4052





Lines of Authority - Non-Standard Business Entity (Agency) Form Name
Consultant (Life & Health)
Consultant (Property & Casualty)
Viatical Settlement Broker

Form 4052 (initial)


Surplus Lines Broker
Form 4052 (initial)
SLB-2
License Type - Reinsurance Intermediary Form Name
Initial Application RI-app
Renewal Application RI-renew

Appointment Form Name
Appointment Form Form 4151
Appointment Cancellation Form Form 4921

RESA Forms Form Name
Title Settlement Agent/Agency Financial Responsibility Certification Form TSA Form
Title Settlement Agent Surety Bond TSA Surety Bond
Waiver of Blanket Fidelity Bond or Employee Dishonesty Insurange Policy for Title Insurance Settlement Agents TSA Waiver
Settlement Agent Registration Form - Individual RESA Individual
Settlement Agent Registration Form - Corporation or Other Legal Entity RESA Corp
Unlicensed Ocean Marine Disclosure Form Form Name
Unlicensed Ocean Marine Disclosure Form Unlicensed Ocean Marine Disclosure Form

Licensing Procedures