Form Ndoi-211 - Business Entity Modification 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 MODIFICATION FORM
For use by Business Entities with an existing Producer license only.
Fees: Adding lines of authority $50. All fees are non-refundable.
Fees are payable to the Nevada Division of Insurance
(Please print or type)
Division Use Only: Fees: ____________ Check #:_____________ Application ID#: _____________ ORG ID # _______________
Approved by: _________________ Date: __________________ License No: ___________________________________________
Business Entity Name
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) Number
Is the business entity affiliated with a financial institution/bank?
7
8
Yes
No
Business Address
City
State
Zip or Foreign Country
9
10
11
12
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 Country
17
18
20
21
19
Nonresident business entities may submit license modifications online through Sircon’s Compliance Express at
or through the National Insurance Producer Registry (NIPR) at
22
This form may be used by resident or nonresident business entities intending to modify existing lines of authority held by the
licensee in this state. It is the entities responsibility to transact business within the scope of its license. Each individual transacting
Nevada business on behalf of the business entity must be authorized to do so through the association process.
List the busines entity’s Nevada license number (s):_________________________________
Is the entity adding lines of authority to an existing license? Yes_____ No______
If yes, indicate the line of authority being added. There must be an individual or individuals authorized to transact for the same line or
combination of lines of authority that the business entity is licensed for.
Life _____ Health _____ Variable Annuity/Life _____ Property _____ Casualty _____ Other:_______________________
The laws and regulations that govern the business of insurance are governed by Title 57 of the Nevada Revised Statutes. The laws and
regulations may be accessed online at
23
The undersigned owner, partner, officer or director of the business entity hereby certifies, under penalty of perjury, that:
1.
The business entity grants permission to the Commissioner of Insurance in the State of Nevada to verify any information supplied
with any federal, state or local government agency, current or former employer or insurance company.
2.
I authorize the State of Nevada to give any information they may have concerning me to any federal, state or municipal agency, or
any other organization, and I release the State of Nevada and any person acting on their behalf from any and all liability of
whatever nature by reason of furnishing such information.
3.
I acknowledge that I am familiar with the insurance laws and regulations of the State of Nevada to which I am applying for
licensure.
4.
If required, I have received a Certificate of Good Standing from the jurisdiction's Secretary of State in which I am applying.
Date: _________________________________________
Signature: _________________________________________________________________________
Must be signed by an officer, director, principal or partner of the business entity
NDOI-211 DOC 325A Business Entity Modification Form (rev 6.30.2015)
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