"Duplicate License/Letter of Certification & Clearance Change of Address or Telephone Number Request" - Mississippi

Duplicate License/Letter of Certification & Clearance Change of Address or Telephone Number Request is a legal document that was released by the Mississippi Department of Insurance - a government authority operating within Mississippi.

Form Details:

  • Released on March 1, 2018;
  • The latest edition currently provided by the Mississippi Department of Insurance;
  • 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 fillable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Department of Insurance.

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501 N. West St.
MIKE CHANEY
1001 Woolfolk State Office Building
Commissioner of Insurance
Jackson, MS 39201
P.O. Box 79
Jackson, MS 39205
STATE OF MISSISSIPPI
Mississippi Insurance Department
www.mid.ms.gov
DUPLICATE LICENSE/LETTER OF CERTIFICATION & CLEARANCE
CHANGE OF ADDRESS OR TELEPHONE NUMBER REQUEST
Duplicate License Fee: $25.00 for individuals and $50.00 for entities
Letter of Certification or Letter of Clearance Fee: $20.00
Change of Address and Telephone Number: No Charge
Change of MS Resident to MS Non-resident: No Charge (if not requesting a clearance letter)
Name of licensee (please print)
*I am requesting
duplicate(s) of license #
*I am requesting
Letter(s) of Certification of license #
(MS resident applying for a non-resident license in another state.)
*I am requesting
Letter(s) of Clearance for license #
(MS resident moving to another state and canceling resident license.)
*I am requesting to change my resident Mississippi license #
to a non-resident Mississippi
license. (Activation of new resident license required within 90 days or MS license will cancel)
*I am changing my Adjuster Designated Home State (ADHS) state from
to
(If changing MS ADHS to another state, a fee is required if requesting a clearance form)
Please make the following address change(s) to license #
Mailing address: (Old)
(New/current)
Resident address:
(New/current)
Telephone Number – (Old)
(New)
Business email Address- (Old)
(New)
Print name of requestor
Date
Signature of requestor
The requested document will be sent to the licensee’s email address. Resident address must be changed by
licensee. For address change: s c a n a n d e mail form to
licensing@mid.ms.gov
or fax 601-359-1951.
Rev. 3-2018
Print Form
Clear Form
501 N. West St.
MIKE CHANEY
1001 Woolfolk State Office Building
Commissioner of Insurance
Jackson, MS 39201
P.O. Box 79
Jackson, MS 39205
STATE OF MISSISSIPPI
Mississippi Insurance Department
www.mid.ms.gov
DUPLICATE LICENSE/LETTER OF CERTIFICATION & CLEARANCE
CHANGE OF ADDRESS OR TELEPHONE NUMBER REQUEST
Duplicate License Fee: $25.00 for individuals and $50.00 for entities
Letter of Certification or Letter of Clearance Fee: $20.00
Change of Address and Telephone Number: No Charge
Change of MS Resident to MS Non-resident: No Charge (if not requesting a clearance letter)
Name of licensee (please print)
*I am requesting
duplicate(s) of license #
*I am requesting
Letter(s) of Certification of license #
(MS resident applying for a non-resident license in another state.)
*I am requesting
Letter(s) of Clearance for license #
(MS resident moving to another state and canceling resident license.)
*I am requesting to change my resident Mississippi license #
to a non-resident Mississippi
license. (Activation of new resident license required within 90 days or MS license will cancel)
*I am changing my Adjuster Designated Home State (ADHS) state from
to
(If changing MS ADHS to another state, a fee is required if requesting a clearance form)
Please make the following address change(s) to license #
Mailing address: (Old)
(New/current)
Resident address:
(New/current)
Telephone Number – (Old)
(New)
Business email Address- (Old)
(New)
Print name of requestor
Date
Signature of requestor
The requested document will be sent to the licensee’s email address. Resident address must be changed by
licensee. For address change: s c a n a n d e mail form to
licensing@mid.ms.gov
or fax 601-359-1951.
Rev. 3-2018
Print Form
Clear Form