Claimant Name Change Request - With Or Without Address Change (Non Assignments) printable pdf download

Claimant Name Change Request - With Or Without Address Change (Non Assignments)

For DFS purposes only;

______________Adjuster

______________date

______________Supervisor

DEPARTMENT OF FINANCIAL SERVICES

Division of Rehabilitation and Liquidation

______________date

Claimant Name Change Request - With or Without Address Change

(Non Assignments)

Company in Liquidation:

Claim #:

Policy #:

Receiver’s ID#/Suffix:

Claimant Name and Address currently on file with Receiver:

Name:

Address:

City:

State:

Zip:

Please enter the new information in the box below and attach the appropriate supporting documentation as

outlined in the instructions. A copy of a valid driver’s license, utility bill or passport reflecting the new information and

legal documentation to support the change(s) (marriage certificate, divorce decree, legal orders, death certificate,

corporate name change filing etc.) must be submitted.

Name:

Address:

City:

State:

Zip:

Phone #:

Email:

Please have your signature notarized below and return this form along with the supporting documentation to: The

Department of Financial Services, Division of Rehabilitation and Liquidation, Attention: Claims Dept. – Change

of Name/Address, 2020 Capital Circle SE Suite 310, Tallahassee, FL 32301.

I swear or affirm that I am the claimant referenced in the claimant name and address section of this form and/or am authorized to sign

this form on the claimant's behalf. I further swear under penalty of law that all information contained on this form as well as all

attachments are true and correct to the best of my knowledge.

____________________________________

_______________________________

Claimant Signature

Date

Relationship to Claimant

State of __________

Sworn to and subscribed to me by _____________ on

County of ________

this ____day of _______, 20___.

________________________

Notary Signature

Claimant Name Change Request - With Or Without Address Change (Non Assignments)

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