License Name Change Request - LIC 075

California Department of Insurance
Producer Licensing Bureau

License Name Change Request
California Insurance Code Section 1650 and 1666.5

300 Capitol Mall
16th floor
Sacramento, CA 95814-4309
(800) 967-9331
www.insurance.ca.gov

LIC 075 (Rev. 09/2022)

This request is only valid for insurance license applicants and individuals who hold an insurance license issued by the California Department of Insurance. This form may not be used for business entities requesting a name change. Business entities should contact our Business Entity Unit at (916) 492-3069 or email them at cdibena@insurance.ca.gov for further information.

The licensee's National Producer Number (NPN) can be retrieved using the following link: NPN Lookup

License Number/Application ID

National Producer Number (NPN)

Email address

Applicant or Licensee's Former Name

First Name

Middle Name

Last Name

Applicant or Licensee's New Name

First Name

Middle Name

Last Name

Reason for Name Change (select one):

Marriage

Divorce

Naturalization

Legal Name Change

Other

Proof of Identity of New Name Government Issued documents that states your new legal name: (a) current driver’s license (b) state issued photo identification card (c) social security number (d) individual taxpayer identification number card (ITIN) (e) marriage certificate, or (f) court documents.

Signature

I certify (or declare) under penalty of perjury, under the laws of the State of California, that I am the licensee or applicant who is requesting a name change. Pursuant to California Insurance Code Section 1650 and 1666.5, I authorize the California Department of Insurance to change the name on my lecense or application to indicate the name shown on this form based on the attached authorized documentation. *

Licensee or Applicant's Signature

Date

City

State/Territory Value is not selected

Phone #

Please allow 12 to 14 business days for processing this request.

License Number/Application ID Number and Email must match what is on file at CDI. Please click Back and correct on first tab.

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License Name Change Request - LIC 075

Applicant or Licensee's Former Name

Applicant or Licensee's New Name

Signature