Form Ndoi 208 - Additional Location Filing Form - Nevada Division Of Insurance
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1Department of Business and Industry
Nevada Division of Insurance
1818 E. College Pkwy, Suite 103, Carson City, Nevada 89706 Phone: (775) 687-0700 Fax: (775) 687-0797 Web: doi.nv.gov
BUSINESS ENTITY
RESIDENT AND NONRESIDENT INSURANCE LICENSE
ADDITIONAL LOCATION FILING FORM
Filing Fee of $10.00 required
Fees are payable by check or money order to the Nevada Division of Insurance, and are nonrefundable.
Division Use Only: Fees: ____________ Check #:_____________ Application ID#: _____________ ORG ID # __________
Approved by: _________________ Date: __________________ License No: ________________________________________
Business Entity Name and Nevada License number.
Incorporation/Formation Date
FEIN
1
2
3
(month) ___(day) ___(year)
-
_______
4
DBA (Provide Nevada County Clerk Filing if required by county)
5
State of Domicile
Country of Domicile
6
If applicable, NASD Firm Central Registration Depository (CRD)
Is the business entity affiliated with a financial institution/bank?
7
8
Number
Yes
No
9
Additional Location Business Address
City
State
Zip or Foreign
10
11
12
Country
Phone Number
Fax Number
Business Web Site Address
Business E-Mail Address
13
14
15
16
(
)
-
(
)
-
Mailing Address
P.O. Box
City
State
Zip or Foreign
17
18
19
20
21
Country
Designated/Responsible Licensed Producer
22
Identify at least one Designated/Responsible Licensed Producer for the above additional location: If the person listed below has not already been affiliated
to the business entity, the person must also complete a license application/affiliation form and pay the applicable fees.
-
-
Name
SSN
-
-
Name
SSN
-
-
Name
SSN
-
-
Name
SSN
Sircon’s Compliance Express
Individual associations and terminations may be submitted online through
at
The modification/affiliation fee is $60 plus any online processing fees.
NDOI 208 DOC 322 Additional Location (rev 11.22.2013)
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