Applicant Name
_________________________
NAIC No.
_________________
FEIN:
_________________
© 2006 National Association of Insurance Commissioners
September 7, 2006
FORM 14
CHANGE OF ADDRESS/CONTACT NOTIFICATION FORM
NAME CHANGE
If there has been a name change as well as an address change, please complete the following:
Previous Company Name: ______________________________________________________________
Current Company Name: _______________________________________________________________
ADDRESS/CONTACT CHANGE
This form is to be completed as a courtesy filing in conjunction with other changes or to notify regulatory
officials of address changes or contact person changes applicable to your Company. For each address change,
please indicate one or more areas for which the change given below is applicable:
Catastrophe/Disaster Coordination Contact
A contact person for state departments to contact for
information if there is a catastrophe or disaster.
Claim Information
A contact person for the public to contact for claim
information.
Consumer Complaints Contact
A contact person for state consumer complaint staff to
contact for resolution of complaints filed with the state
department.
Form and/or Rate Filings Contact
A person for state departments to contact regarding issues
on policy forms filings or rate filings.
Local Office in Domestic/Foreign State Contact A person for the public or state departments to contact.
Managing General Agent
A person for the public or state departments to contact.
Policyholder Information
A person for the public to contact.
Producer Licensing Contact (Appointment)
A person for state departments to contact regarding issues
of producer licensing or appointments of agents.
Regulatory Compliance/Government Relations
A person for state departments to contact on matters
related to regulation but unrelated to public complaints
filed with the state department.)
Premium Tax Contact
A person for