Kansas Insurance Department

Change of Business Entity (Agency) Information

This form must be submitted to the Insurance Department within thirty (30) working days of any changes in an agency’s Designated Responsible Licensed Person (DRLP) or DBA name. All other changes in addresses, names, email and other contact information must be submitted online via NIPR. Failure to report such changes may result in action against the agency's license. This form is not to be used for changes in information for individual licensed producers.

AGENCY IDENTIFICATION INFORMATION
9 Digit Federal Tax ID No:
Agency Name:
Agency Address:
Current Telephone:

PLEASE COMPLETE EACH AREA BELOW WHICH APPLIES

Change of Legal Name or DBA Name
New Legal Name:
New DBA Name:

Change of Designated Responsible Licensed Producer (DRLP)
Please provide his or her National Producer Number (NPN), their full name and residence address. The Designated/Contact person must hold an agent license in the state of Kansas except for Credit and Portable Electronic only agency licenses.
Name:
Residence Address:
City: State: Zip:
NPN:

By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Signature:
Date: 05/30/2023