DEPARTMENT OF BANKING AND INSURANCE
DIVISION OF INSURANCE
PO BOX 329
TRENTON, NJ 08625-0329
TEL (609) 292-5316
FAX (609) 984-2792
Visit us on the Web at dobi.nj.gov
New Jersey is an Equal Opportunity Employer • Printed on Recycled Paper and Recyclable
ADDRESS CHANGE REQUEST FORM
Licensee Name: _____________________________________
New Jersey License Number: __________________________
Record Update:
__ Home Address Record:
Street:_______________________________________________________________________
City:_________________________________ State: ________ Zip Code: _______________
Phone: _______________________ Fax: ____________________________
Email _____________________________
__ Business Location Address Record:
Name of Business: _____________________________________________________________
Street:________________________________________________________________________
City:_________________________________ State: ___________ Zip Code: _____________
Phone: _______________________ Fax: ____________________________
Email ___________________________________________
__ Mailing Address Record:
Street:________________________________________________________________________
P.O. Box: ________________________________
City:_________________________________ State: ___________ Zip Code: _____________
Signature of Licensee or Business Entity Representative: ____________________________
Date: _____________
Note: If change is for a business entity, the request must be signed by an owner, officer or Designated
Responsible Producer (DRLP).
2018
