Licensee Name Address Change Request Form
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1FIN533 | 0215
LICENSEE NAME/ADDRESS CHANGE REQUEST FORM
THIS FORM IS TO BE USED TO CHANGE THE MAILING, RESIDENT, OR BUSINESS ADDRESS; OR AN INDIVIDUAL’S NAME
THIS FORM WILL NOT BE PROCESSED IF NOT FILLED OUT COMPLETELY
Agencies must make name change on LDTL form FIN528
Licensees are required to notify TDI within 30 days of an address change (TIC § 4001.252)
TDI License Number ____________________________________________________________________
LOCATED ON BOTH LICENSE AND RENEWAL APPLICATION
Name of Agent/Agency
______________________________________________________________
NAME SHOWN ON LICENSE
Name Change __________________________________________________________________________
FOR INDIVIDUALS ONLY–(New name) Supporting official court documentation (e.g. marriage certificate, divorce decree, or other official court
document) is required to be submitted with this form.
An agency requesting a name change must submit a completed LDTL form FIN528.
After a name or address change has been processed, you may print a copy of your license from the internet. Please
see “How do I get a copy of my license?” at
OFFICIAL MAILING ADDRESS:
This is the official address for all notifications from the department including renewal
notice, delivery of original and renewed license, service of process and all correspondence from the department.
_________________________________________________________________________________
STREET, PHYSICAL LOCATION, ROUTE OR P.O. BOX NUMBER
_________________________________
_____________________
____________________
CITY
STATE
ZIP CODE
OFFICIAL RESIDENT ADDRESS:
(INDIVIDUALS ONLY) This is the address where you live and the address on your
driver license. This address is used to determine the state of residence for licensing purposes.
NOTE: Any change of address resulting in a move from Texas to another state or from one non-resident state to another will
require a Letter of Certification from the licensee’s new state of residence to be submitted with this form for consideration.
_________________________________________________________________________________
STREET, PHYSICAL LOCATION
_________________________
__________________________
_________________________
CITY
STATE OF DRIVER LICENSE ISSUE
ZIP CODE
BUSINESS ADDRESS:
This address is the physical location of an agent’s or agency’s office. It is for reference purposes
only, and will not be used for official correspondence from this department.
________________________________________________________________________________________
STREET, PHYSICAL LOCATION, OR ROUTE (P.O. BOX NOT ALLOWED)
________________________________________
_________________________
_________________________
CITY
STATE
ZIP CODE
Daytime Phone Number: _________________________
E-mail Address: _____________________________
Signature:
_______________________________________________
______________________
DATE SIGNED
Print Name:
__________________________________________________________________________________
COMPLETED FORM MAY BE MAILED, E-MAILED, OR FAXED TO:
Texas Department of Insurance - P.O. Box 149104, MC 107-1A Austin, Texas 78714-9104
LICENSE@tdi.texas.gov
FAX: (512) 490-1029
Texas Department of Insurance |
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