(Form AL-A 04/2011) State of Alabama Department of ...
(Form AL-A 04/2011)
State of Alabama Department of Insurance Notice of Address Change
(Form AL-A) Please use this form to report an address change. Note that according to Section 27-7-17(B), Code of Alabama 1975, a licensee is required to notify the Department of Insurance of an address change within 30 days of that change. Failure to comply with this statute results in a penalty of $50.00.
Licensees are encouraged to report all address changes online at ; however, at this time NIPR is unable to process changes to email addresses without also changing other addresses.
PLEASE COMPLETE EACH SECTION OF THIS FORM ? ALL INFORMATION IS REQUIRED UNLESS OTHERWISE NOTED
Licensee's Full Name: _____________________________________________________________________
National Producer #, SSN, or FEIN: __________________________________________________________
Alabama License #: ______________________________________________________________________
E-mail Address: __________________________________________________________________________
New E-mail Address: _____________________________________________________________________
Home Phone #: _________________________________(Individual Licensees Only)
Business Phone #: _______________________________ Fax #: ___________________________________
Date of Request: __________________________________________________________________________
COMPLETE THE FOLLOWING IF APPLICABLE:
Home Address Change: _________________________________________________________________
_________________________________________________________________
Business Address Change: _______________________________________________________________
_______________________________________________________________ Licensee's mailing address must be provided below, even if it is the same as an address change indicated above. This will be the address to which all Producer Licensing documents will be mailed.
Mailing Address:
__________________________________________________________________
__________________________________________________________________
Mailing address is (Check One) Home _______ Business _______ Other ________
* Mail this request to: AL DEPT OF INSURANCE PRODUCER LICENSING DIVISION P O BOX 303351 MONTGOMERY, AL 36130-3351
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