DEPARTMENT OF BUSINESS & INDUSTRY - Nevada Division …



Individual Name Change Form

(Please print clearly or type)

It is the licensee’s responsibility to file any name change with the Nevada Division of Insurance (“Division”). Persons with questions regarding name changes should contact the Division’s Licensing Section in Carson City at (775) 687-0700, option 2 or email nevada.licensing@doi..

Complete the information below for the licensed individual whose name is to be changed, then scan and email the form to nevada.licensing@doi. for processing.

Nevada residents must include a copy of an updated driver’s license, government-issued photo identification card, passport or court document that shows the name change.

Non-residents must include documentation showing the name has already been changed with their resident state’s insurance department.

Individuals who are required to maintain a surety bond for licensure must submit a surety bond rider from the surety company which includes the name change.

CURRENT INFORMATION:

|Current Name (Print the full name of the licensee currently shown on the license) |Nevada License No. (or NPN) |

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|Signature of Licensee |Date |

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NEW INFORMATION:

|New Individual Name (Last, First, MI, Jr/Sr) |

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CONFIRM CONTACT INFORMATION (this information will be used to update the licensee’s record):

|Resident Phone No. |Business Phone No. |Email Address |

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|Resident Address (Physical Address) |City |State |Zip or Foreign Country|

| | | | |

|Mailing Address/P.O. Box |City |State |Zip or Foreign Country|

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DIVISION USE ONLY:

|Received Date: |Processed Date: |Staff Initials: |

| | | |

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Department of Business and Industry

Nevada Division of Insurance

1818 E. College Pkwy, Suite 103, Carson City, Nevada 89706 / Phone: (775) 687-0700 / Web:

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