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Do not use this form. Office of Market Regulation | Bureau of Licensing & Enforcement | Licensing Services Division 1209 Strawberry Square | Harrisburg, Pennsylvania 17120 Phone: 717.787.3840 | Fax: 717.787.8553 | www.insurance.pa.gov. Name and Address Change Form - Individuals.
Due to limited staffing and resources, we ask that you please utilize this service. Office of Market Regulation | Bureau of Licensing & Enforcement | Licensing Services Division 1209 Strawberry Square | Harrisburg, Pennsylvania 17120 Phone: 717.787.3840 | Fax: 717.787.8553 | www.insurance.pa.gov. Name and Address Change Form (Revised 06/13)
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The process becomes more difficult for insurance adjusters. If your home state issues adjuster licenses you can submit address changes via NIPR’s Address Change Request system. However, if you are an insurance adjuster and have a designated home state (DHS), you have to change addresses with each state insurance department individually.
Submit contact change request for any license on NIPR's Producer Database (PDB) Submit Email Changes; Submit Phone number Changes; Submit change to state code of residence address for non-residents only. Address must match respective resident/home state license address. Submit change to state code of business address for non-residents only.
Business entities may update contact information including physical address (es), email address (es), phone number (s), name (s) and fax number (s). To complete this form you will need to provide your: Resident state license number, National Producer Number (NPN) FEIN. Date of birth.
Applicant's Kansas license record must be active on the Producer Database (PDB) before completing a Contact Change Request (CCR) transaction. Applicant must have a resident license on PDB to submit a CCR for Kansas. Resident applicants must maintain a resident address in Kansas. Non-Resident applicants' resident address must not be in Kansas.
To submit your change of address, print this form, complete it in full, and mail it to: Combined Insurance Company of America Policyholder Services PO Box 6703 Scranton, PA 18505-0703 If you have any questions, please call our Customer Service department at 1-800-225-4500 during regular business hours, 7:30 a.m. to 6:00 p.m., CST.
