Due within 10 days of effective date of change.

Instructions for Completing Form

Name of the Purchasing Group, Group contact name and email address
The name of the purchasing group should be shown exactly as it was on the original registration form. If there have been multiple name changes, the purchasing group's most recent name change should be provided. Do not use abbreviations. Please complete all sections.

Purchasing Group Name, Address, Phone Number & Email Address
Select appropriate box of item that is changing. In the New Information section, please provide email address, as all correspondence will now be done electronically.

Delete Current Insurer
Select box if deleting existing company. Please provide the company's name and NAIC number in the New Information section.

Add New Company
Select box if adding a new insurance company. Please provide the company's name and NAIC number in the New Information section.

Delete Agent
Select box if deleting an agent. Please provide the name, address, phone number and license number in the New Information section.

Change Agent
Select box if adding a new agent. Please provide name, address, phone number, email address and license number in the New Information section.

Delete State
Select box if withdrawing from a state in which the group is presently registered.

Change Purchasing Group Officer
Select box if the group is changing an officer. Please provide the new officer's name, address and new position in the New Information section.

Change Purchasing Group Contact
Select box if the group's contact is to be changed. Please provide new contact's name, address, phone number and email address in the New Information section.

Other
Please select box for all other changes. Please provide the necessary information including name, address, phone number and email address in the New Information section.

Change in Registration for Purchasing Groups Form