"Request to Change the Designated Responsible Licensed Producer" - New Hampshire

Request to Change the Designated Responsible Licensed Producer is a legal document that was released by the New Hampshire Insurance Department - a government authority operating within New Hampshire.

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Download "Request to Change the Designated Responsible Licensed Producer" - New Hampshire

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The State of New Hampshire
Insurance Department
21 South Fruit Street Ste 14
Concord NH 03301
(603) 271-0203 Fax (603)271-7029
TDD Access: Relay NH 1-800-735-2964
www.nh.gov/insurance
John Elias
Alex Feldvebel
Commissioner
Deputy Commissioner
Request to Change the Designated Responsible Licensed Producer
Per RSA 402-J:6 IIb The business entity has designated a licensed producer responsible for the
business entity's compliance with the insurance laws, rules, and regulations of this state.
The Designated Responsible Licensed Producer (DRLP) must remain actively licensed for the lines of authority
held by the agency. Cumulatively the lines of authority held by the DRLP(s) must equal the lines held by the
entity.
To change the DRLP we require either this form or a written request advising us of the change, signature of the
new DRLP and a $50 amendment fee. Changes cannot be completed online and cannot be processed during the
renewal process. Failing to comply jeopardizes the license of the entity.
Name of the Entity:
FEIN:
NH License Number:
or
NPN:
Previous DRLP Name:
NH License number:
or
NPN:
Line(s) of Authority:
Please state Action : Remove the Previous DRLP and Replace with individual listed below
Keep the Previous DLRP and Add a second DRLP
Name of New DRLP:
NH License number
or
NPN:
Line(s)of Authority:
Signature of the New DRLP:
Mail form and amendment fee of $50 , check made payable to the NH Insurance Department to:
NH Insurance Department
21 South Fruit St Ste 14
Concord NH 03301
603-271-0203
The State of New Hampshire
Insurance Department
21 South Fruit Street Ste 14
Concord NH 03301
(603) 271-0203 Fax (603)271-7029
TDD Access: Relay NH 1-800-735-2964
www.nh.gov/insurance
John Elias
Alex Feldvebel
Commissioner
Deputy Commissioner
Request to Change the Designated Responsible Licensed Producer
Per RSA 402-J:6 IIb The business entity has designated a licensed producer responsible for the
business entity's compliance with the insurance laws, rules, and regulations of this state.
The Designated Responsible Licensed Producer (DRLP) must remain actively licensed for the lines of authority
held by the agency. Cumulatively the lines of authority held by the DRLP(s) must equal the lines held by the
entity.
To change the DRLP we require either this form or a written request advising us of the change, signature of the
new DRLP and a $50 amendment fee. Changes cannot be completed online and cannot be processed during the
renewal process. Failing to comply jeopardizes the license of the entity.
Name of the Entity:
FEIN:
NH License Number:
or
NPN:
Previous DRLP Name:
NH License number:
or
NPN:
Line(s) of Authority:
Please state Action : Remove the Previous DRLP and Replace with individual listed below
Keep the Previous DLRP and Add a second DRLP
Name of New DRLP:
NH License number
or
NPN:
Line(s)of Authority:
Signature of the New DRLP:
Mail form and amendment fee of $50 , check made payable to the NH Insurance Department to:
NH Insurance Department
21 South Fruit St Ste 14
Concord NH 03301
603-271-0203