DEPARTMENT OF INSURANCE

Name	Statham, Mark Richard	DOIID	891735	NAIC NPN	17702172

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date
Inactive	Non Resident	Agent	Life	9/17/2015	3/31/2019
Inactive	Non Resident	Agent	Health	9/17/2015	3/31/2019
Inactive	Non Resident	Agent	Casualty	5/15/2017	3/31/2019
Inactive	Non Resident	Agent	Property	5/15/2017	3/31/2019

*If a status is Pending, Pending Replacement,or the record displays Affidavit on File, click on them for more details.

No License Renewal Information

NOTE: Licensee may renew up to 6 months prior to Next Compliance Date. Licensees subject to CE must complete CE requirements before Next Compliance Date in order to successfully complete the License Renewal Process.

Address Information

Type	Address
Residence	Not Public Information
Business / Home Office	16229 N 123rd Dr Surprise, AZ 853783609

Phone Information

Type	Phone
Business / Home Office	(612) 940-0869