"Adjuster Designation of Home State Form" - Kentucky

Adjuster Designation of Home State Form is a legal document that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky.

Form Details:

  • Released on May 1, 2012;
  • The latest edition currently provided by the Kentucky 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 printable version of the form by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download "Adjuster Designation of Home State Form" - Kentucky

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Adjuster DHS Form (5/2012)
COMMONWEALTH OF KENTUCKY
DEPARTMENT OF INSURANCE
P. O. Box 517
Frankfort, Kentucky 40602-0517
email:
DOI.AgentLicensingMail@ky.gov
http://insurance.ky.gov
502-564-6004
fax: 502-564-6030
ADJUSTER DESIGNATION OF HOME STATE FORM
To be completed by Kentucky non-resident-licensed Adjusters
(PLEASE PRINT OR TYPE)
Non-Resident Adjuster’s Full Name: _______________________________________
DOI License # or NPN: ________________ Domiciled State*:____________________
*Note: The “Domiciled State” is the state in which the adjuster maintains his, her, or its
principal place of residence or business.
I am a non-resident, licensed adjuster in Kentucky, and I wish to designate the state of
_______________________ as my Adjuster home state.
NOTE: You must select a state in which you currently hold an ACTIVE adjuster
license.
If you…….
 passed the KY adjuster exam,
 AND do not reside in KY or have principal place of business in KY,
 THEN DOI will correct your adjuster license to “non-resident,”
 AND DOI will add the Adjuster Designated Home State identified above.
Attestation:
I hereby attest that, under penalty of perjury, all of the information submitted above is
true and complete. I am aware that submitting false information or omitting pertinent or
material information in connection with this form is grounds for license revocation, and
may subject me monetary penalties.
______________________________________________________
Signature of Adjuster
______________________________________________________
Date
You may submit by email to DOI.AgentLicensingMail@ky.gov, fax to 502-564-
6030, U.S. Mail to address above, or upload through your Individual eServices
account, by selecting “Add Requested Documents.”
Adjuster DHS Form (5/2012)
COMMONWEALTH OF KENTUCKY
DEPARTMENT OF INSURANCE
P. O. Box 517
Frankfort, Kentucky 40602-0517
email:
DOI.AgentLicensingMail@ky.gov
http://insurance.ky.gov
502-564-6004
fax: 502-564-6030
ADJUSTER DESIGNATION OF HOME STATE FORM
To be completed by Kentucky non-resident-licensed Adjusters
(PLEASE PRINT OR TYPE)
Non-Resident Adjuster’s Full Name: _______________________________________
DOI License # or NPN: ________________ Domiciled State*:____________________
*Note: The “Domiciled State” is the state in which the adjuster maintains his, her, or its
principal place of residence or business.
I am a non-resident, licensed adjuster in Kentucky, and I wish to designate the state of
_______________________ as my Adjuster home state.
NOTE: You must select a state in which you currently hold an ACTIVE adjuster
license.
If you…….
 passed the KY adjuster exam,
 AND do not reside in KY or have principal place of business in KY,
 THEN DOI will correct your adjuster license to “non-resident,”
 AND DOI will add the Adjuster Designated Home State identified above.
Attestation:
I hereby attest that, under penalty of perjury, all of the information submitted above is
true and complete. I am aware that submitting false information or omitting pertinent or
material information in connection with this form is grounds for license revocation, and
may subject me monetary penalties.
______________________________________________________
Signature of Adjuster
______________________________________________________
Date
You may submit by email to DOI.AgentLicensingMail@ky.gov, fax to 502-564-
6030, U.S. Mail to address above, or upload through your Individual eServices
account, by selecting “Add Requested Documents.”