Kansas Insurance Department
Producer Licensing DivisionChange of Business Entity (Agency) Status
1300 SW Arrowhead Rd
Topeka KS 66604
This form must be submitted to the Insurance Department within thirty (30) working days of any changes in an agency’s legal and/or mailing address, email address, name change, and DBA name change. Failure to report such changes may result in a monetary penalty.
THIS FORM MUST BE SUBMITTED ELECTRONICALLY TO THE DEPARTMENT. QUESTIONS ABOUT COMPLETION OF THE FORM CAN BE DIRECTED TO THE PRODUCER LICENSING DIVISION.