REQUEST TO CHANGE RESIDENT STATE

This form must be submitted to the Insurance Department if licensee is a resident producer moving to another state. All other changes in addresses, email, and other contact information must be submitted online via Contact Change Request to NIPR.

CURRENT CONTACT INFORMATION:

Name:  
Email: 
NPN: 

RESIDENCE ADDRESS MOVING FROM:

Address: 
        
           
Date no longer residing at this address:

RESIDENCE ADDRESS MOVING TO:

Address: 
        
           
Date moving to this address:

*If you are moving from Kansas, your license will be converted to a nonresident license. However, you must obtain an insurance producer license in your new resident state within 90 days of moving to the new state. Failure to do so will result in cancellation of your Kansas nonresident license.

If you are moving to Kansas from another state, email kid.licensing@ks.gov for best practice to obtain your resident license. You will be required to submit a resident license application through NIPR and will be subject to additional licensing requirements required for Kansas resident license applicants before being eligible to receive 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.

Date: 10/03/2022