Kansas Department of Insurance

REQUEST TO CHANGE RESIDENT STATE

Submit this form when the producer is moving to a new resident state. If the producer will remain a Kansas nonresident licensee, first submit the information using the contact change request on NIPR, then submit this form to update the domicile state on the producer licensee file.
All contact changes that do not affect a resident state change shall be submitted through the contact change request on NIPR.

CURRENT CONTACT INFORMATION:

Name:
Email:
NPN:
Are you currently licensed as a resident (R) or nonresident (NR) producer in Kansas?

RESIDENCE ADDRESS MOVING FROM:

Address:

State:
Date no longer residing at this address:

RESIDENCE ADDRESS MOVING TO:

Address:

State:
Date moving to this address:

If you are moving from Kansas, your license will be converted to a nonresident license. You are required to obtain an active resident license within 30 days moving from Kansas. Failure to obtain an active resident status will result in cancellation of your Kansas nonresident license.

If you are moving to Kansas from another state, after reviewing your request, we will email detailed instructions on how to obtain a Kansas resident license. The process will include submitting a resident application through NIPR, providing supporting documents, and undergoing a review for approval to obtain a Kansas resident license. See Resident Producer Licensing for more information.

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: 11/21/2024