"Address Change Request Form" - New Hampshire

Address Change Request Form is a legal document that was released by the New Hampshire Insurance Department - a government authority operating within New Hampshire.

Form Details:

  • Released on July 1, 2018;
  • The latest edition currently provided by the New Hampshire 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 New Hampshire Insurance Department.

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Download "Address Change Request Form" - New Hampshire

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The State of New Hampshire
Insurance Department
21 South Fruit Street, Suite 14
Concord, NH 03301
John Elias
Alexander K. Feldvebel
Commissioner
Deputy Commissioner
Revised July 2018
PRODUCERS----ADJUSTERS----BUSINESS ENTITIES
ADDRESS CHANGE REQUEST
Adjusters & Producers shall notify this Department within 30 days of an address change.
There are three ways to update address information:
1. Individual Producers and Adjusters with a license on the national database may change all address
information electronically including emails without a fee via
www.nipr.com
. Select Contact Changes
2. Producers and Adjusters can change address information electronically by subscribing to our subscription
Online Licensee Service; see website for details
3. Manual Instructions: MAIL completed form and fee to the Department. Please complete all sections.
Make checks payable to “NH Insurance Department”
Manually processed address changes require a $10 fee per NHRSA 400-A:29.
Address changes will not be processed manually without the required fee
Print new license for free by selecting LICENSE STATUS on our homepage
www.nh.gov/insurance
Licensee Name_______________________________________
Social Security Number /FEIN or NH License Number or National Producer Number ______________________
Current residential physical location address (not a post office box)
Resident address is for Individuals only.
Street _____________________________________________
City/Town___________________________________________
State and zip code_____________________________________
Home Phone _________________________________________
Current business address
FOR ADJUSTERS ONLY
Business Name________________________________________
Street________________________________________________
_________________________
City/Town ___________________________________________
Designated Home State
State and zip code______________________________________
(Only for adjusters that reside in states
Business Email ________________________________________
that do not issue resident adjuster licenses)
Business Phone ________________________________________
Please note, to select NH as your
Designated home state, you
MUST pass the NH licensing
exam and complete NH
approved CE for future
renewals.
Mailng address to receive correspondence.
Street/rural route/postal box ____________________________
City/Town____________________________________________
State and zip code______________________________________
Licensee Signature and Date_______________________________
Department Use Only:
$10 Processing Fee Received______________
The State of New Hampshire
Insurance Department
21 South Fruit Street, Suite 14
Concord, NH 03301
John Elias
Alexander K. Feldvebel
Commissioner
Deputy Commissioner
Revised July 2018
PRODUCERS----ADJUSTERS----BUSINESS ENTITIES
ADDRESS CHANGE REQUEST
Adjusters & Producers shall notify this Department within 30 days of an address change.
There are three ways to update address information:
1. Individual Producers and Adjusters with a license on the national database may change all address
information electronically including emails without a fee via
www.nipr.com
. Select Contact Changes
2. Producers and Adjusters can change address information electronically by subscribing to our subscription
Online Licensee Service; see website for details
3. Manual Instructions: MAIL completed form and fee to the Department. Please complete all sections.
Make checks payable to “NH Insurance Department”
Manually processed address changes require a $10 fee per NHRSA 400-A:29.
Address changes will not be processed manually without the required fee
Print new license for free by selecting LICENSE STATUS on our homepage
www.nh.gov/insurance
Licensee Name_______________________________________
Social Security Number /FEIN or NH License Number or National Producer Number ______________________
Current residential physical location address (not a post office box)
Resident address is for Individuals only.
Street _____________________________________________
City/Town___________________________________________
State and zip code_____________________________________
Home Phone _________________________________________
Current business address
FOR ADJUSTERS ONLY
Business Name________________________________________
Street________________________________________________
_________________________
City/Town ___________________________________________
Designated Home State
State and zip code______________________________________
(Only for adjusters that reside in states
Business Email ________________________________________
that do not issue resident adjuster licenses)
Business Phone ________________________________________
Please note, to select NH as your
Designated home state, you
MUST pass the NH licensing
exam and complete NH
approved CE for future
renewals.
Mailng address to receive correspondence.
Street/rural route/postal box ____________________________
City/Town____________________________________________
State and zip code______________________________________
Licensee Signature and Date_______________________________
Department Use Only:
$10 Processing Fee Received______________