"Third Party Administrator Change of Name & Address Form" - Rhode Island

Third Party Administrator Change of Name & Address Form is a legal document that was released by the Rhode Island Department of Business Regulation - a government authority operating within Rhode Island.

Form Details:

  • Released on December 17, 2008;
  • The latest edition currently provided by the Rhode Island Department of Business Regulation;
  • 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 Rhode Island Department of Business Regulation.

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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Business Regulation
INSURANCE DIVISION
1511 Pontiac Ave Bldg 69-2
Cranston, R.I. 02920
Telephone No. (401) 462-9520
FAX No. (401) 462-9559
www.dbr.ri.gov
TDD No. 711
THIRD PARTY ADMINISTRATOR CHANGE OF NAME & ADDRESS FORM
RIGL27-20.7-12 (h) notification of change - Duty of License. Every licensee shall notify the
commissioner of any changes in the licensee’s residential or business address within thirty days of the
change. Any licensee who ceases to maintain residency in this state shall deliver the insurance license
to the commissioner by personal delivery or by mail within thirty days after terminating residency.
• If this is a change in name or state of domicile, and your company holds a Certificate of
Authority or Waiver Certificate, please include a check for your fee of $25, made payable to
General Treasurer, State of Rhode Island for an updated certificate.
Name (as it appears on your
original license)
Federal Identification Number
State of Domicile
NAME CHANGE
Change of Name
From
To
:
:
NEW BUSINESS ADDRESS
Is this change a result of a change in the state of domicile?
Agency Name (If Applicable)
Street Address
Address Line 2
City
State Zip Code
Date Change Becomes Effective
Business Telephone Number
Business Fax Number
Business E-Mail Address
(
)
(
)
NEW MAILING ADDRESS
Agency Name (If Applicable)
Street Address
Address Line 2
City
State Zip Code
Date Change Becomes Effective
Business Telephone Number
Business Fax Number
Business E-Mail Address
(
)
(
)
You will receive a new certificate reflecting any change in resident address or a change in your name.
A change in mailing address will be marked on our records.
____________________
___________________
__________
Signature
Title
Date .
Revision 12/17/08
Page 1 of 1
TPA Change of Name & Address
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Business Regulation
INSURANCE DIVISION
1511 Pontiac Ave Bldg 69-2
Cranston, R.I. 02920
Telephone No. (401) 462-9520
FAX No. (401) 462-9559
www.dbr.ri.gov
TDD No. 711
THIRD PARTY ADMINISTRATOR CHANGE OF NAME & ADDRESS FORM
RIGL27-20.7-12 (h) notification of change - Duty of License. Every licensee shall notify the
commissioner of any changes in the licensee’s residential or business address within thirty days of the
change. Any licensee who ceases to maintain residency in this state shall deliver the insurance license
to the commissioner by personal delivery or by mail within thirty days after terminating residency.
• If this is a change in name or state of domicile, and your company holds a Certificate of
Authority or Waiver Certificate, please include a check for your fee of $25, made payable to
General Treasurer, State of Rhode Island for an updated certificate.
Name (as it appears on your
original license)
Federal Identification Number
State of Domicile
NAME CHANGE
Change of Name
From
To
:
:
NEW BUSINESS ADDRESS
Is this change a result of a change in the state of domicile?
Agency Name (If Applicable)
Street Address
Address Line 2
City
State Zip Code
Date Change Becomes Effective
Business Telephone Number
Business Fax Number
Business E-Mail Address
(
)
(
)
NEW MAILING ADDRESS
Agency Name (If Applicable)
Street Address
Address Line 2
City
State Zip Code
Date Change Becomes Effective
Business Telephone Number
Business Fax Number
Business E-Mail Address
(
)
(
)
You will receive a new certificate reflecting any change in resident address or a change in your name.
A change in mailing address will be marked on our records.
____________________
___________________
__________
Signature
Title
Date .
Revision 12/17/08
Page 1 of 1
TPA Change of Name & Address