The Service Request Form must be used by licensed individual or business entity Producers or Adjusters, or Bail and Recovery Agents, to request either: (1) Change of Legal Name; (2) Addition or Removal of an Alias/Other Name; (3) Correction of Social Security Number (SSN), Date of Birth (DOB), or Federal Employer Identification Number; or (4) Cancellation of License of Particular Line(s) of Authority. Note: Additional documentation may be required. Please submit the form and additional documentation to the contact at the top of the form. Please also allow 3-5 business days to process the request. Changes may be confirmed online at www.nipr.com or www.sircon.com/Indiana.
IMPORTANT NOTICE: Letters of Clearance are no longer issued by the Indiana Department of Insurance. A change in license status (e.g., license cancellation/voluntary surrender) may be viewed online through the National Insurance Producer Registry. Changes of address, telephone, email, fax, or an addition or removal of a business entity’s Designated Responsible Licensed Producer (DRLP), are also no longer done through this form. Contact information must be updated online through www.nipr.com or www.sircon.com/Indiana. DRLPs must be maintained online through a business entity’s AgencyEDGE account or at www.sircon.com/Indiana by selecting “Maintain your firm association” on the left-hand side.
A change in legal name or address must be reported not more than thirty (30) days after the change, pursuant to IC 27-1-15.6-7.