Form FIN540 "Agency Address Change Request Form" - Texas

What Is Form FIN540?

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

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Texas Department of Insurance;
  • 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 fillable version of Form FIN540 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form FIN540 "Agency Address Change Request Form" - Texas

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FIN540 | 1019
Clear form
Agency address change request form
You must fill out and send us this document within 30 days of an official change to an agency’s
address. This form must also be signed by an officer or partner.
���� FIN528 must be filled out for an agency name change.
Name of agency:
________________________________________________________________________________________________________
TDI license number:
____________________________________________________________________________________________________
Current resident state:
__________________________________________________________________________________________________
Fill out all parts of this section if your address or phone number changed:
Mailing address
Street address
_____________________________________________________________________________________________________
City
State
ZIP
__________________________________________________
_______________________________
____________________
���� Attach a copy of a Letter of Certification if changing your resident state.
Business address
Street address
_____________________________________________________________________________________________________
City
State
ZIP
__________________________________________________
_______________________________
____________________
Phone number
Business
(________)________________________________________________________________________________________________________
Contact person
Name ________________________________________________ Email
___________________________________________________
Sign here:
The answers I gave on this form are true and correct:
________________________________________________________________________________________________________
Officer or partner signature
Date
_____________________________________________________________________________________________________________________________
Print name
Texas Department of Insurance
1/2
FIN540 | 1019
Clear form
Agency address change request form
You must fill out and send us this document within 30 days of an official change to an agency’s
address. This form must also be signed by an officer or partner.
���� FIN528 must be filled out for an agency name change.
Name of agency:
________________________________________________________________________________________________________
TDI license number:
____________________________________________________________________________________________________
Current resident state:
__________________________________________________________________________________________________
Fill out all parts of this section if your address or phone number changed:
Mailing address
Street address
_____________________________________________________________________________________________________
City
State
ZIP
__________________________________________________
_______________________________
____________________
���� Attach a copy of a Letter of Certification if changing your resident state.
Business address
Street address
_____________________________________________________________________________________________________
City
State
ZIP
__________________________________________________
_______________________________
____________________
Phone number
Business
(________)________________________________________________________________________________________________________
Contact person
Name ________________________________________________ Email
___________________________________________________
Sign here:
The answers I gave on this form are true and correct:
________________________________________________________________________________________________________
Officer or partner signature
Date
_____________________________________________________________________________________________________________________________
Print name
Texas Department of Insurance
1/2
FIN540 | 1019
Contact us if you have questions:
You can: (1) email License@tdi.texas.gov, or (2) call 512-676-6500.
Know your rights:
You have the right to see and get facts we have about you: You must ask us in writing. You might need
to pay to get a copy of this information. You can send your letter or email one of these ways:
Email:
OpenRecords@tdi.texas.gov
Mail:
Texas Department of Insurance
Fax: 512-490-1021
Public Information Coordinator
In person: 333 Guadalupe, Austin, Texas 78701
PO Box 149104 (Mail code 110-1C)
Austin, Texas 78714-9104
You have the right to ask that we fix information we have about you that is wrong: You must ask us in
writing. The letter or email must have: (1) your name and mailing address, (2) your phone number,
(3) details about what needs to be fixed, and (4) the reason or proof showing why the information is wrong.
You can send your letter or email one of these ways:
Email:
RecordCorrections@tdi.texas.gov]
Mail:
Texas Department of Insurance
Fax: 512-490-1025
Record Correction Request
In person: 333 Guadalupe, Austin, Texas 78701
PO Box 149104 (Mail code 113-1C)
Austin, Texas 78714-9104
Submit
Texas Department of Insurance
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