Form AG11 "Change of Agency Status" - Kansas

What Is Form AG11?

This is a legal form that was released by the Kansas Insurance Department - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the Kansas Insurance Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form AG11 by clicking the link below or browse more documents and templates provided by the Kansas Insurance Department.

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Download Form AG11 "Change of Agency Status" - Kansas

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KANSAS INSURANCE DEPARTMENT
CHANGE OF
PRODUCER LICENSING DIVISION
AGENCY STATUS
1300 SW ARROWHEAD RD
TOPEKA, KS 66604
Phone: (785) 296-7862 Fax: (785) 368-7019 Email:
KID.Licensing@ks.gov
This Form May Be Duplicated
Instructions:
Please TYPE or PRINT
This form must be submitted to the Insurance Department within thirty (30) working days of the effective date of the agent additions or within
thirty (30) days of the effective date of agent terminations. Failure to report such changes will result in a monetary penalty. It is the agency’s
responsibility to notify insurance companies of changes. IF CONFIRMATION IS DESIRED, SUBMIT THIS FORM IN DUPLICATE
WITH A POSTAGE PAID ENVELOPE.
AGENCY IDENTIFICATION NO.—REQUIRED FOR PROCESSING
(9 Digit Federal Tax ID No. and 3 Digits Assigned by Department):
AGENCY NAME:
ADDRESS:
TELEPHONE:
PLEASE COMPLETE ANY AREA BELOW THAT APPLIES
] TERMINATION OF AGENCY CONTRACT WITH COMPANY (Do not report termination until after run-off period is over if
[
there is a need to service policies.)
Name of Company(ies)
Date of Termination
[
]
CHANGE OF AGENCY ADDRESS
[
] LEGAL
[
] MAILING
Street Address
City, State, Zip
New Telephone No.
New Fax No.
Email Address
[
]
CHANGE OF OWNERS, OFFICERS, OR DIRECTORS/DESIGNATED PERSON
If there have been any changes of proprietors, officers, directors, or partners, attach a current listing. Please give full name, title, and
residence address. If changing the designated person, please provide his or her National Producer Number (NPN). The Designated/Contact
person must be licensed and listed on the agency license as such.
[
]
CHANGES OF PERSONNEL (Licensed in Kansas) If deleting agents because they have moved from the state or are deceased,
please advise.
Check One
Full Name
Residence Address
NPN/License # Affiliation/Deletion
Add
Delete
Effective Date
SIGNATURE OF DESIGNATED PERSON
(As Assigned by Agency):
Date:
AG11 (11/19)
KANSAS INSURANCE DEPARTMENT
CHANGE OF
PRODUCER LICENSING DIVISION
AGENCY STATUS
1300 SW ARROWHEAD RD
TOPEKA, KS 66604
Phone: (785) 296-7862 Fax: (785) 368-7019 Email:
KID.Licensing@ks.gov
This Form May Be Duplicated
Instructions:
Please TYPE or PRINT
This form must be submitted to the Insurance Department within thirty (30) working days of the effective date of the agent additions or within
thirty (30) days of the effective date of agent terminations. Failure to report such changes will result in a monetary penalty. It is the agency’s
responsibility to notify insurance companies of changes. IF CONFIRMATION IS DESIRED, SUBMIT THIS FORM IN DUPLICATE
WITH A POSTAGE PAID ENVELOPE.
AGENCY IDENTIFICATION NO.—REQUIRED FOR PROCESSING
(9 Digit Federal Tax ID No. and 3 Digits Assigned by Department):
AGENCY NAME:
ADDRESS:
TELEPHONE:
PLEASE COMPLETE ANY AREA BELOW THAT APPLIES
] TERMINATION OF AGENCY CONTRACT WITH COMPANY (Do not report termination until after run-off period is over if
[
there is a need to service policies.)
Name of Company(ies)
Date of Termination
[
]
CHANGE OF AGENCY ADDRESS
[
] LEGAL
[
] MAILING
Street Address
City, State, Zip
New Telephone No.
New Fax No.
Email Address
[
]
CHANGE OF OWNERS, OFFICERS, OR DIRECTORS/DESIGNATED PERSON
If there have been any changes of proprietors, officers, directors, or partners, attach a current listing. Please give full name, title, and
residence address. If changing the designated person, please provide his or her National Producer Number (NPN). The Designated/Contact
person must be licensed and listed on the agency license as such.
[
]
CHANGES OF PERSONNEL (Licensed in Kansas) If deleting agents because they have moved from the state or are deceased,
please advise.
Check One
Full Name
Residence Address
NPN/License # Affiliation/Deletion
Add
Delete
Effective Date
SIGNATURE OF DESIGNATED PERSON
(As Assigned by Agency):
Date:
AG11 (11/19)