Fillable FORM L-CHG: LICENSE INFORMATION CHANGE: (Arizona)

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FORM L-CHG: LICENSE INFORMATION CHANGE: (Arizona)

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Licensing Section
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-4457 | Toll-free: (877) 660-0964
Web: https://insurance.az.gov | E-mail: Licensing@azinsurance.gov
Form L-CHG (Rev. 20180618)
FORM L-CHG: LICENSE INFORMATION CHANGE
NOTE: Individuals (resident or non-resident) updating address, phone or e-mail information should,
INSTEAD, use the NIPR Address Change Request (http://nipr.com/).
Print the full name of the licensee currently shown on the license
Arizona Insurance License Number
If licensee is a business entity, print the full name of the individual requesting the change
SIGNATURE of licensee or, for a business entity, the individual requesting the change
Date
NAME CHANGE: Below, complete [A] for a licensed business entity or [B] for a licensed individual. An Arizona-
resident individual must include a copy of an updated government-issued photo identification card. An Arizona-
resident business entity must provide evidence that the name was legally changed with the Arizona Corporation
Commission or similar entity. A non-resident must ensure the resident state has already processed the name change
prior to submitting this form.
[A] BUSINESS
►
New Name (if license holder is a business entity; otherwise, leave blank)
[B] INDIVIDUAL
►
Last Name
First Name
Jr./Sr./III/etc.
ADDRESS CHANGE: Enter NEW address information below
BUSINESS
ADDRESS
Business Name (if applicable)
Physical Street Address
City
State
ZIP Code
MAILING
ADDRESS
Business Name (if applicable)
Street Address or P O Box
City
State
ZIP Code
HOME
ADDRESS (if
individual)
Physical Street Address
City
State
ZIP Code
E-MAIL
(optional)
E-mail Address (optional)
PHONE NUMBER CHANGE: Enter NEW telephone number information below
Business Telephone Number
Home Telephone Number
Fax Number
DESIGNATED PRODUCER (DRLP) CHANGE: If adding a DRLP, the new DRLP must sign this form
acknowledging the DRLP designation and accepting responsibility for the business-entity licensee’s compliance
with Arizona laws per ARS § 20-285(C)(3).
Add
Delete
AZ License #
Last Name
First Name
Signature of DRLP (only if adding)
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FORM L-CHG: LICENSE INFORMATION CHANGE: (Arizona)

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Completed 12 August 2020

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