"Request to Change Residency Moving to or From Connecticut" - Connecticut

Request to Change Residency Moving to or From Connecticut is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on June 1, 2018;
  • The latest edition currently provided by the Connecticut Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Insurance Department.

ADVERTISEMENT
ADVERTISEMENT

Download "Request to Change Residency Moving to or From Connecticut" - Connecticut

958 times
Rate (4.7 / 5) 57 votes
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
REQUEST TO CHANGE RESIDENCY
MOVING TO OR FROM CONNECTICUT
This form is only to be used if you are moving into or out of the State of Connecticut.
• Are you trying to change your Connecticut license from: Resident to Non-Resident status: □ Yes □ No
• Are you trying to change your Connecticut license from: Non-Resident to Resident status: □ Yes □ No
Select to
Update license Information (address, email or individual name)
Note: You should contact your new resident state prior to making any changes to your Connecticut resident
license. The new resident state may require a
Letter of Certification or Letter of Clearance
from Connecticut.
Licensee’s Information - (Type or Print)
1. Individual or Business Entity Name: ______________________________________________________
2. National Producer Number (NPN): _______________________________________________________
3. Individual last 4 digits of SSN or Business Entity last 4 digits of FEIN: ____________________________
4. Type of License (i.e. Producer, Adjuster): __________________________________________________
Demographic Changes – (Type or Print)
1. Old Resident Address: _________________________________________________________________________
Street
City
State
Zip Code
2. Old Business Name/Address: ____________________________________________________________________
Business Name
__________________________________________________________________________________________
Street
City
State
Zip Code
3. New Resident Address: ________________________________________________________________________
Street
City
State
Zip Code
4. New Business Name: __________________________________________________________________________
Name
5. New Business Address*: _______________________________________________________________________
Street
City
State
Zip Code
6. New Mailing Address: _________________________________________________________________________
Street
City
State
Zip Code
7. Phone: _(____)______________________________(_____)_____________________________(__________)__
Resident or Cell
Business
Ext.
8.
Email: ______________________________________________________________________________________
Email
Page 1 of 2
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
REQUEST TO CHANGE RESIDENCY
MOVING TO OR FROM CONNECTICUT
This form is only to be used if you are moving into or out of the State of Connecticut.
• Are you trying to change your Connecticut license from: Resident to Non-Resident status: □ Yes □ No
• Are you trying to change your Connecticut license from: Non-Resident to Resident status: □ Yes □ No
Select to
Update license Information (address, email or individual name)
Note: You should contact your new resident state prior to making any changes to your Connecticut resident
license. The new resident state may require a
Letter of Certification or Letter of Clearance
from Connecticut.
Licensee’s Information - (Type or Print)
1. Individual or Business Entity Name: ______________________________________________________
2. National Producer Number (NPN): _______________________________________________________
3. Individual last 4 digits of SSN or Business Entity last 4 digits of FEIN: ____________________________
4. Type of License (i.e. Producer, Adjuster): __________________________________________________
Demographic Changes – (Type or Print)
1. Old Resident Address: _________________________________________________________________________
Street
City
State
Zip Code
2. Old Business Name/Address: ____________________________________________________________________
Business Name
__________________________________________________________________________________________
Street
City
State
Zip Code
3. New Resident Address: ________________________________________________________________________
Street
City
State
Zip Code
4. New Business Name: __________________________________________________________________________
Name
5. New Business Address*: _______________________________________________________________________
Street
City
State
Zip Code
6. New Mailing Address: _________________________________________________________________________
Street
City
State
Zip Code
7. Phone: _(____)______________________________(_____)_____________________________(__________)__
Resident or Cell
Business
Ext.
8.
Email: ______________________________________________________________________________________
Email
Page 1 of 2
IMPORTANT NOTE: If you do not have a resident license showing on NIPR/PDB within 90 days
of this request, your non-resident Connecticut license will be cancelled.
*The business address must be the physical location where you work.
Signature: __________________________________________ Date Signed: __________________________
Print Name: ________________________________________________________________________________
Contact Phone Number: ______________________________________________________________________
Email (if different from above): ________________________________________________________________
Email completed forms to: cid.licensing@ct.gov, Attn: Residency Change Request
Incomplete forms will not be updated.
Page 2 of 2
Revised: 06/2018
Page of 2