License Variable Life and Variable Annuity Authority Request - LIC 073

California Department of Insurance

Variable Contract Authority Request
California Insurance Code Section 1758.1

300 Capitol Mall
16th floor
Sacramento, CA 95814
Licensing Hotline: (800) 967-9331

Fax: (916) 327-6907
www.insurance.ca.gov

LICDOCUMENTS@INSURANCE.CA.GOV

LIC 073 (Rev. 9/2022)

In order to have Variable Life and Variable Annuity authority added to an active Life-Only agent license, an individual must be registered with the Financial Industry Regularity Authority (FINRA) and approved for California. BrokerCheck - Find a broker, investment or financial advisor (finra.org)

All information requested on this form is required or the request will not be processed. This request is only valid for individuals who hold an active insurance license issued by the California Department of Insurance.

License Number/Application ID

Central Registration Depository (CRD) Number

Licensee's First Name

Licensee's Middle Name

Licensee's Last Name

LICENSEE'S CERTIFICATION: I certify (or declare) under penalty of perjury, under the laws of the State of California, that I am the licensee who is requesting that Variable Contract authority be added to my license. Pursuant to Insurance Code Sections 1758.1, I authorize the California Department of Insurance to add Variable Contract authority to my license.

Licensee's Signature

Date

Please allow 12 to 14 business days for processing this request.

License Number/Application ID Number and Email must match what is on file at CDI. Please click Back and correct on first tab.

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License Variable Life and Variable Annuity Authority Request - LIC 073