Kansas Insurance Department
Producer Licensing DivisionChange of Business Entity (Agency) Status
AG11

1300 SW Arrowhead Rd
Topeka KS 66604
785-296-7862/KID.Licensing@ks.gov

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.

AGENCY IDENTIFICATION NO.—REQUIRED FOR PROCESSING
  

Current Address:    


PLEASE COMPLETE EACH AREA BELOW WHICH APPLIES


  







   




   



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 with the exception of Credit and Portable Electronic.

    


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.

Date: 10/27/2021