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Entity Name Change / Assumed Name (DBA) Request Form
Use this form to register assumed names of currently licensed people and entities. You may also use it to
change the official name of a currently licensed entity.
Filing fee for reinsurance intermediary: $500
Filing fee for other agents or entities: $50
What are you registering?
Assumed name Official name change of licensed entity
Agent’s or entity’s TDI license number ___________________________________________
Social Security number of the agent or Federal Employer Identification
Number (FEIN) of the entity:
___________________________
Name of agent or entity: _____________________________________________________________________________
Enter the exact name as shown on your license. Do not put assumed name or new entity name in this space.
Assumed name or new name of entity
_________________________________________________________________________________________________________________
To register an a
ssumed name, enter the exact assumed name as it's shown on the assumed name
certificate. To register an entity name change, enter the exact new name of entity as it's reflected in the
entity’s official name change document.
Assumed name means any name other than a true name or present legal name. You must attach a
copy of an assumed name certificate that has been led with the county clerk’s office of the county in which
the assumed name will be used if the assumed name:
In the case of a person, is a name that does not include the person's last name or family name.
In the case of a partnership, is a name that does not include the last name or other legal name of
each partner.
In the case of a person or partnership, is a name, including a last name, that suggests the existence
of additional owners by including words such as “Company,” “& Company,” “& Sons,” “&
Associates,” “Brothers,” or similar words, but not words that merely describe the business or
professional service.
In the case of a limited partnership (LP), a corporation, a limited liability partnership (LLP), or a limited
liability company (LLC), any name other than the name in its certificate of formation or a comparable
document. A corporation, LP, LLP, or LLC may le a copy of assumed name certificate that has been
led with the Texas Secretary of State rather than the county clerk.
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New
name of entity means the new official name of a currently licensed entity. You must attach
either:
a) a copy of the certificate of amended registration reflecting the official entity name change that was
led with the Texas Secretary of State’s office.
or
b) a copy of the certificate of name change that was led with any other authorizing entity. A
partnership must attach a copy of the official name change as shown in the amendments to
the partnership agreement.
Have you attached all required documents? Yes No
Attach the assumed name certificate, if required. Each entity must attach: (1) a copy of the assumed
name or a copy of the official document verifying the change of the entity’s name, and (2) adjustment of
nancial responsibility requirement by either an endorsement to its errors and omissions policy extending
coverage to include the assumed name or listing the new entity name as a named insured on the policy.
An entity that meets its nancial responsibility requirement with a bond must provide a rider to the bond
that reflects the entity’s new name. An entity changing its official name must attach its current
license.
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Certification
I certify that the information submitted on this form is true and correct and that I have attached all
information requested. I also certify that I am aware of the licensing provisions in the Texas Insurance
Code and the provisions of Title 28, Texas Administrative Code, Sections 19.901 and 19.902, relating to the
registration of assumed names.
________________________________ ________ ________________________________________
Signature of agent or entity’s officer or partner Print name
____________________________________ ______ ____ ____ ____ _________
Daytime phone number of person signing Email address of person signing
Questions
If you have any questions or need help, contact Customer Service at 512-676-6500 or license@tdi.texas.gov.
Instructions
Send the completed form, attachments, and required fee by:
Regular mail to: UPS and Fedex to:
Agent and Adjuster Licensing Texas Department of Insurance
Texas Department of Insurance Attn: Lockbox Department
P.O. Box 12069, MC: CO-AAL 208 E. 10th St, MC: CO-AAL
Austin, Texas 78711-2069 Austin, Texas 78711
Your rights: You can request information we have about you by emailing OpenRecords@tdi.texas.gov or
writing to: Public Information Coordinator, Texas Department of Insurance, PO Box 12030 (mail code GC-ORO)
Austin, Texas 78711-2030. You also have the right to ask that we fix information we have about you that is
wrong. To ask for a correction, send (1) your name, mailing address, and your phone number, (2) details about
what needs to be fixed, and (3) the reason or proof showing why the information is wrong. Send this by email
to RecordCorrections@tdi.texas.gov or by mail to: Record Correction Request, Texas Department of Insurance,
PO Box 12030 (mail code CO-AAL-CC), Austin, Texas 78711-2030.
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