Official State of Rhode Island website

State of Rhode Island Department of Business Regulation

Insurance Company Termination "FOR CAUSE" Notice Individual & Business Entity

Form for an Insurance Company to report a statutory termination for cause

R.I. Gen. Laws § 27-2.4-16 requires a separate notification to the Insurance Commissioner when an insurance producer is terminated for cause. “For cause” terminations are defined by R.I. Gen. Laws § 27-2.4-14. All such terminations are required to be reported using this form.

Notification MUST be submitted to the Insurance Commissioner within thirty (30) days of the “for cause” termination. R.I. Gen. Laws § 27-2.4-16(a)

A copy of the notification MUST be provided to the insurance producer within fifteen (15) days of termination. R.I. Gen. Laws § 27-2.4-16(a)

Person submitting this form
Compliance contact if different from the person submitting this form
Terminated insurance producer
Termination details
Were there any Rhode Island consumers identified as affected by the insurance producer’s actions that lead to the termination for cause?
If there were any Rhode Island consumer affected, has the company made those consumers whole?
Which statute(s) under R.I. Gen. Laws § 27-2.4-14 has been violated. (check all that apply)

In addition to the submission of this form, the following supporting documentation is required:

  • A summary narrative of the investigation. 
  • If the licensee is a Rhode Island resident, provide a copy of the investigation.
  • If there are Rhode Island consumers who were identified as affected by the insurance producer’s actions that lead to the termination for cause, provide a copy of the investigation.
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