KANSAS INSURANCE DEPARTMENT........ CHANGE OF AG11 Agency Status Ag11form
User Manual: AG11
Open the PDF directly: View PDF 
.
Page Count: 1
KANSAS INSURANCE DEPARTMENT CHANGE OF
PRODUCER LICENSING DIVISION AGENCY STATUS
420 SW 9th
TOPEKA, KS 66612-1678
Phone: (785) 296-7862 Fax: (785) 368-7019 Email: KID.Licensing@ks.gov This Form May Be Duplicated
Instructions: Please TYPE or PRINT
This form must be submitted to the Insurance Department within thirty (30) working days of the effective date of the agent additions or within
thirty (30) days of the effective date of agent terminations. Failure to report such changes will result in a monetary penalty. It is the agency’s
responsibility to notify insurance companies of changes. IF CONFIRMATION IS DESIRED, SUBMIT THIS FORM IN DUPLICATE
WITH A POSTAGE PAID ENVELOPE.
AGENCY IDENTIFICATION NO.—REQUIRED FOR PROCESSING
(9 Digit Federal Tax ID No. and 3 Digits Assigned by Department):
AGENCY NAME:
ADDRESS:
TELEPHONE:
PLEASE COMPLETE ANY AREA BELOW THAT APPLIES
[ ] TERMINATION OF AGENCY CONTRACT WITH COMPANY (Do not report termination until after run-off period is over if
there is a need to service policies.)
Name of Company(ies)
Date of Termination
[ ] CHANGE OF AGENCY ADDRESS [ ] LEGAL [ ] MAILING
Street Address City, State, Zip New Telephone No. New Fax No.
Email Address
[ ] CHANGE OF OWNERS, OFFICERS, OR DIRECTORS/DESIGNATED PERSON
If there have been any changes of proprietors, officers, directors, or partners, attach a current listing. Please give full name, title, and
residence address. If changing the designated person, please provide his or her National Producer Number (NPN). The Designated/Contact
person must be licensed and listed on the agency license as such.
[ ] CHANGES OF PERSONNEL (Licensed in Kansas) If deleting agents because they have moved from the state or are deceased,
please advise.
Check One
Add Delete
Full Name
Residence Address
NPN/License #
Affiliation/Deletion
Effective Date
SIGNATURE OF DESIGNATED PERSON
(As Assigned by Agency): Date:
AG11 (12/17)
