DEPARTMENT OF BANKING AND INSURANCE
DIVISION OF INSURANCE
PO BOX 329
TRENTON, NJ 08625-0329
TEL (609) 292-5316
FAX (609) 984-2792
REQUEST FOR LICENSE SURRENDER/STATUS CHANGE
Licensee Name: ___________________________________________________________ (Type or Print)
N.J. License Number: _________________________
Please place a check next to only one item below. This form must be signed and dated at the bottom.
□ Voluntary Surrender:
1. Selection of Voluntary Surrender will result in the termination of the licensee’s Producer and/or Public Adjuster license.
□ Nonresident to Resident:
1. All licensees must notify this office within 30 days of any change in residence, business location, and\or mailing address (status
change without address change is possible);
2. An individual licensee must qualify for a resident license by completing required Prelicensing education and passing line of authority
examinations unless the request for resident status occurs within 90 days of the former Home State license termination or it’s status
change to nonresident;
3. All individuals seeking a resident license status and all unlicensed Officers, Partners, Directors, Owners, and Members of a business
entity seeking a status change shall complete the electronic fingerprinting process administered by MorphoTrust. Instructions and
necessary forms are available at https://www.state.nj.us/dobi/insliced/livescan.htm. The requested status change will not be approved
until the criminal history report generated from the electronic fingerprint scan is reviewed. Failure to complete the required electronic
scan will result in termination of the license;
4. A business entity seeking to change its status to a New Jersey resident license must provide the business name approval request form
(https://www.state.nj.us/dobi/insliced/busnameapprov.pdf) a copy of the original business certificate stamped “filed” by the
appropriate agency, and have all officers, directors, partners, and owners of 10% or more complete the electronic fingerprinting
process if they are not an active resident licensee in this State;
5. The status change from nonresident to resident does not require a fee or submission of an application. Failure to comply with the
requirements of this section will result in the termination of the license and reinstatement will require submission of a $40 fee and
completed application if submitted prior to the scheduled license expiration date, or qualifying as a new applicant if beyond the
scheduled license term.
□ Resident to Nonresident:
1. An individual or business entity seeking to change their license status from a resident to nonresident shall notify the Department of the
change of address and other contact information and provide evidence of obtaining a resident license in the new Home State within 30
days. Failure to provide the required notification will result in termination of the license. Reinstatement within the scheduled license
term will require submission of a complete application and $40.00 fee. Reinstatement beyond the scheduled expiration date will
require qualifying as a new applicant.
□ Please update my residence and\or business address (Please attached the Change of Address Form). □ No Address Change.
Signature of Individual Licensee; or DRLP, Owner, Officer or Director of Business Entity: ___________________________________________
Date: _______________________________________
