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State of New Jersey
DEPARTMENT OF BANKING AND INSURANCE
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ICENSING SERVICES BUREAU - INSURANCE
PO BOX 327
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RENTON, NJ 08625-0327
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EL (609) 292-7272
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AX (609) 984-5263
Visit us on the Web at www.dobi.nj.gov
New Jersey is an Equal Opportunity Employer •
Printed on Recycled Paper and Recyclable
CHANGE OF DESIGNATED RESPONSIBLE PRODUCER FORM
Every licensed business entity must designate a licensed insurance producer (DRLP) for the business entity’s
compliance with the insurance laws, rules and regulations of this State. A business entity may have more than
one DRLP. The lines of authority on a business entity license must be supported by the same line of authority
on the DRLP(s) license. Failure to have all lines of authority on a business entity license matched by a line of
authority on a DRLP’s license, will result in the removal of the effected line(s) from the business entity license.
The Department must be advised of all changes of DRLP as they occur. Please fax this form to the
Department at 609-984-5263 to advise the Department of changes in DRLP.
___________________________________________________________________________
Business Entity Producer License #:_________________________________________________
Business Entity Name and Address:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
…………………………………………………………………………………………………………………………………………
A. Addition of Designated Responsible Licensed Producer
Name of Individual NJ licensed Producer to be added as DRLP:
_________________________________________________
NJ Insurance Producer #:____________________
……………………………………AND/OR………………………………………………………………………………………
B. Deletion of Designated Responsible Licensed Producer:
Name of Individual NJ licensed Producer to be deleted as DRLP:
_________________________________________________
NJ Insurance Producer #:________________________________
………………………………………………………………………………………………………………………………………...
REQUIRED SIGNATURES (2)
________________________________________ _________
Signature of owner, officer or director (specify title) DATE
________________________________________________________ ____________
Signature of Designated Responsible Licensed Producer to be added DATE
