Request for Name Change


Please use this form to request a name change. Note that according to Section 27-7-17(B), Code of Alabama 1975, a licensee is required to notify the Department of Insurance of a legal change in name within 30 days of that change. For verification purposes, a legal name change for an individual is when the name is changed with the Social Security Administration. A legal name change for a business entity occurs when the proper filing is made with the proper authority in the entity’s state of organization. Failure to comply with this statute will result in a $50 penalty.

For individual licensees, this form must be accompanied by a copy of a social security card in the new name or the receipt from the Social Security Administration showing legal name change.

For business entities, this form must be accompanied by a new Certificate of Existence from the Alabama Secretary of State.

Request for Name Change (Form AL-B)

Please enter your Alabama license number, the effective date that the name was changed with the Social Security Office, and an email address where we can send confirmation that your documentation has been uploaded successfully. Then upload your completed form and documentation.

Documentation MUST be combined into ONE file AND in pdf format.

This Name Change is for:

Alabama Insurance License Number:
 

Email Address:
 

Effective Date: *THIS WILL BE THE DATE ON SSN CARD / ALSOS DOCS*

Former Last Name:
 

Current Last Name:
 

Upload Form:
 

For security purposes, you must check the checkbox below (and follow any puzzle prompts it may give you).