STATE OF NEVADA - Nevada Division of Insurance



Address Change Request (ACR)

In an ongoing effort to streamline the licensing process, the Division has implemented and encourages the use of its new electronic functionality. The new services are efficient, generally paper free. By clicking on the Producer Address Change Request (ACR) link, an individual may update their address online utilizing the National Insurance Producers Database. The electronic Producer Address Change Request (ACR) is a free service.

Business entities MUST utilize the hard copy address notification submission.

Paper submissions: Please do not include “SAME” in the different address fields.

Name of Licensee: (Individual or Entity)

_______________________________________________________________________________________

FEIN, Social Security Number or License Number, and Designated Home State

________________________________________________________________________________________

Mailing Address:

________________________________________________________________________________________

________________________________________________________________________________________

Business Physical Address:

________________________________________________________________________________________

________________________________________________________________________________________

Business Phone No: __________________ Business Fax No: ______________________________________

E-mail Address: ___________________________________________________________________________

Business Web site Address: _________________________________________________________________

Individual’s Home Address: __________________________________________________________________

Home Phone No: __________________________________________________________________________

________________________________________________________

(Signature of licensee or representative of the business entity) (Date)

Division Use Only:

Processed by: ________________________________Date:____________________

NDOI-241 DOC 316 Address Change Request (rev 1.11.11)

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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 Fax: (775) 687-0787 Web: doi.

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