Change Form

BULLETIN 94-03 TO: All Licensees SUBJECT: Change Form The division, with input from a committee of licensees, has developed the attached Change Form to be used by licensees to amend licenses and/or to make required notifications to the division. The Change Form explains the filing requirements for the various changes listed below and will expedite the license amendment and/or notification process for licensees and the division. THE CHANGE FORM IS NOT A LICENSE APPLICATION. Licensees wishing to add a new license class, e.g., adding the surplus lines broker class to an existing producer-license, must submit an application form. The Change Form may be used, however, to add lines of insurance to an existing license class, e.g., adding disability to a life producer license. The Change Form may be used for the following changes: Employment Termination of employment Residence address (physical and/or mailing) Business address (physical and/or mailing) Telephone number (residence, business, or fax, if applicable) Name (individual, firm, or DBA/Fictitious, if applicable) Change in lines Fiduciary account Suspension, revocation or disciplinary action of a license by another state or jurisdiction Conviction of a felony or misdemeanor Residency status Firm principal or manager Compliance officer Cancellation of license Please remember that AS 21.27.025(a) requires a licensee to notify the director in writing by certified mail within 30 days of a change in his/her license. Failure to comply with this requirement will result in the following penalties and may result in the suspension or revocation of the license (3 AAC 31.060(a)(2)). If notification is received: (a) 1 to 60 days late, $50.00; (b) 61 to 120 days late, $100.00; and (c) more than 120 days late, $260.00. The division is pleased to be able to provide the "Change Form" to you. We encourage you to use this form should any change noted above occur. The Change Form may be photocopied, though additional copies are also available upon request from the division. Dated this 7th day of February, 1994, in Juneau, Alaska. Click Here for Form 08-1245.pdf