*All fields are required.
*If Nonresident, check box to affirm that name change is complete with home state prior to Kansas name change. The Department will verify completion of name change in home state via NIPR’s Producer Database (PDB).
Current Name on License:
Legal Name Change Request:
Reason for Name Change:
Attestation: By checking this box, I affirm that the information I have provided is true and correct. I understand that action may be taken against my license upon finding the information provided in this form is incorrect or misleading.
NOTE: Kansas resident Licensees must submit documentation, such as a government issued ID, court document, etc. showing proof of legal name change before this request will be processed. You must submit the documentation through NIPR Attachment Warehouse.