Get MI DIFS FIS 0262 2011

This will serve as your confirmation of the change. FIS 0262 5/13 Department of Insurance and Financial Services Name or Address Change for Insurance Licensees Required Information about your current license System ID / License Number 7-digit number assigned by DIFS Name as it currently appears on your insurance license Full Employer ID number business entity OR Last 4 digits of your Social Security Number Check box to indicate each item you are changing. If you change your name or mailing address we will mail a new license document to the most recent mailing address on file with our office. No fees required for use of this form* Requirement Attach document s as legal proof of name change such as driver s license marriage certificate amended articles of incorporation new dba ling etc* Last name First name Middle initial/name Suffix Jr. Sr. I II etc* Change my individual name to Change my Agency Corporation Partnership and/or DBA name to Change my MAILING ADDRESS to EFFECTIVE DATE of Mailing Address change Address line 1 IMPORTANT NOTE ON MAILING ADDRESS CHANGES Address change must be reported to DIFS within 30 days of move City State/Province ZIP/Postal Code Change my Residence address to Country Change my Business address to Change my Personal email address to Certification of individual or authorized licensed producer business entities I certify that the information given on and attached to this form is complete and correct. When complete please send this form and any attachments to Signer s name and title typed or printed Mailing and delivery address Signature DIFS Insurance Licensing P. O. Box 30220 Lansing MI 48909-7720 Date signed Authority PA 218 of 1956 as amended* Submission is required to report changes to an insurance licensee s name mailing address changes and other information* Failure to file may result in an action against license s held including a monetary fine and/or license suspension or revocation*. No fees required for use of this form* Requirement Attach document s as legal proof of name change such as driver s license marriage certificate amended articles of incorporation new dba ling etc* Last name First name Middle initial/name Suffix Jr. Sr. I II etc* Change my individual name to Change my Agency Corporation Partnership and/or DBA name to Change my MAILING ADDRESS to EFFECTIVE DATE of Mailing Address change Address line 1 IMPORTANT NOTE ON MAILING ADDRESS CHANGES Address change must be reported to DIFS within 30 days of move City State/Province ZIP/Postal Code Change my Residence address to Country Change my Business address to Change my Personal email address to Certification of individual or authorized licensed producer business entities I certify that the information given on and attached to this form is complete and correct. Sr. I II etc* Change my individual name to Change my Agency Corporation Partnership and/or DBA name to Change my MAILING ADDRESS to EFFECTIVE DATE of Mailing Address change Address line 1 IMPORTANT NOTE ON MAILING ADDRESS CHANGES Address change must be reported to DIFS within 30 days of move City State/Province ZIP/Postal Code Change my Residence address to Country Change my Business address to Change my Personal email address to Certification of individual or authorized licensed producer business entities I certify that the information given on and attached to this form is complete and correct. When complete please send this form and any attachments to Signer s name and title typed or printed Mailing and delivery address Signature DIFS Insurance Licensing P. .