Form COR-1 "Change of Record Form (Change of Name/Trade Name)" - Louisiana

What Is Form COR-1?

This is a legal form that was released by the Louisiana Department of Insurance - a government authority operating within Louisiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Louisiana Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form COR-1 by clicking the link below or browse more documents and templates provided by the Louisiana Department of Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form COR-1 "Change of Record Form (Change of Name/Trade Name)" - Louisiana

Download PDF

Fill PDF online

Rate (4.4 / 5) 55 votes
Louisiana Department of Insurance
Change of Record Form (Change of Name/Trade Name)
Submit via fax to (225) 342-3754 or by e-mail to
producerlicensing@ldi.la.gov
SECTION #1- ADDING A TRADE NAME TO AN INDIVIDUAL/ENTITY LICENSE
Add Trade Name to Individual License
Add Trade Name to Business Entity License
I presently hold license #________________ issued in the following name:____________________________________________
I wish to have my license record amended to indicate that I am authorized to use this TRADE NAME.
________________________________________________________________________________________________________
Print new Trade Name
Current mailing address_____________________________________________________________________________________
Street Address or P.O. Box
City
State
Zip
Contact e-mail __________________________________________________________
_______________________________________________________
________________________
Signature of licensee/Authorized entity personnel
Date
SECTION #2 – NAME CHANGE FOR AN INDIVIDUAL LICENSE ONLY
Proof of legal name change is required. A copy of an updated Driver’s License name is acceptable.
I presently hold license #________________ issued in the following name:____________________________________________
I have changed my name to_________________________________________________________________________________
Current mailing address______________________________________________________________________________________
Street Address or P.O. Box
City
State
Zip
Contact e-mail __________________________________________________________
__________________________________________________
________________________
Signature of Individual Changing Name
Date
SECTION #3 – NAME CHANGE FOR AN ENTITY
I presently hold license #________________ issued in the following name:____________________________________________
I have changed my name to__________________________________________________________________________________
Current mailing address______________________________________________________________________________________
Street Address or P.O. Box
City
State
Zip
Contact e-mail __________________________________________________________
_________________________________ ____________________________________
______________
Signature of Authorized Agency Representative
Printed Name of Agency Representative
Date
Form COR-1
Rev. May 2016
Louisiana Department of Insurance
Change of Record Form (Change of Name/Trade Name)
Submit via fax to (225) 342-3754 or by e-mail to
producerlicensing@ldi.la.gov
SECTION #1- ADDING A TRADE NAME TO AN INDIVIDUAL/ENTITY LICENSE
Add Trade Name to Individual License
Add Trade Name to Business Entity License
I presently hold license #________________ issued in the following name:____________________________________________
I wish to have my license record amended to indicate that I am authorized to use this TRADE NAME.
________________________________________________________________________________________________________
Print new Trade Name
Current mailing address_____________________________________________________________________________________
Street Address or P.O. Box
City
State
Zip
Contact e-mail __________________________________________________________
_______________________________________________________
________________________
Signature of licensee/Authorized entity personnel
Date
SECTION #2 – NAME CHANGE FOR AN INDIVIDUAL LICENSE ONLY
Proof of legal name change is required. A copy of an updated Driver’s License name is acceptable.
I presently hold license #________________ issued in the following name:____________________________________________
I have changed my name to_________________________________________________________________________________
Current mailing address______________________________________________________________________________________
Street Address or P.O. Box
City
State
Zip
Contact e-mail __________________________________________________________
__________________________________________________
________________________
Signature of Individual Changing Name
Date
SECTION #3 – NAME CHANGE FOR AN ENTITY
I presently hold license #________________ issued in the following name:____________________________________________
I have changed my name to__________________________________________________________________________________
Current mailing address______________________________________________________________________________________
Street Address or P.O. Box
City
State
Zip
Contact e-mail __________________________________________________________
_________________________________ ____________________________________
______________
Signature of Authorized Agency Representative
Printed Name of Agency Representative
Date
Form COR-1
Rev. May 2016