"Name Change Application" - Delaware

Name Change Application is a legal document that was released by the Delaware Department of Insurance - a government authority operating within Delaware.

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OFFICE OF THE
STATE OF DELAWARE
DEPARTMENT OF INSURANCE
COMMISSIONER
NAME CHANGE APPLICATION
Please select type of company.
(This form only applies to the following company types.)
Advisory Organization
Premium Finance Company
Rating Organization
Reinsurance Intermediary
Third Party Administrator (TPA)
COMPLETED BY:
Printed Contact Name:
Date:
Signature:
Title:
Address:
Phone:
E-Mail Address:
COMPANY INFORMATION:
Former Name:
New Name:
Home Office Address:
Mailing Address:
Phone:
FEIN:
1351 West North Street, Suite 101, Dover, DE 19904 • insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
OFFICE OF THE
STATE OF DELAWARE
DEPARTMENT OF INSURANCE
COMMISSIONER
NAME CHANGE APPLICATION
Please select type of company.
(This form only applies to the following company types.)
Advisory Organization
Premium Finance Company
Rating Organization
Reinsurance Intermediary
Third Party Administrator (TPA)
COMPLETED BY:
Printed Contact Name:
Date:
Signature:
Title:
Address:
Phone:
E-Mail Address:
COMPANY INFORMATION:
Former Name:
New Name:
Home Office Address:
Mailing Address:
Phone:
FEIN:
1351 West North Street, Suite 101, Dover, DE 19904 • insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
REQUIREMENTS:
1. ☐ Attach copy of the name change approval from the company’s state of domicile.
2. ☐ Surrender original License (Certificate of Authority). If unable to locate original license include
Affidavit of Lost License
(UCAA Form
15).
3. ☐ Attach amended or restated Articles of Incorporation or Organization certified by the domicile
state.
4. ☐ Attach amended by-laws (if applicable) certified by the Secretary of the Company.
5. ☐ Designation of Person to receive Service of Process –
Form
D1.
6. ☐
Fees are subject to retaliatory provision pursuant to
18 Del. C. §
532. If the domicile state fees are less than
those described below, remit the Delaware fees as follows:
$110 – Name change with amended Articles of Incorporation (AOI)
$120 – Name change with amended AOI and amended by-laws
Check must be made payable to Delaware Department of Insurance (only checks with the correct
payee will be accepted).
Mail to:
Company Regulation (BERG)
Delaware Department of Insurance
1351 West North Street, Suite 101
Dover, DE 19904
To ensure prompt processing of your application make sure all requirements have been met.
Questions may be directed to
BERG@delaware.gov
or 302-674-7330.
1351 West North Street, Suite 101, Dover, DE 19904 • insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
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