DEPARTMENT OF FINANCIAL SERVICES Division of Rehabilitation and Liquidation www.floridainsurancereceiver.org For DFS purposes only; ______________Adjuster ______________date ______________Supervisor ______________date Claimant Address Change Only Request Company in Liquidation: Claim #: Policy #: Receiver’s ID#/Suffix: Claimant Name and Address currently on file with Receiver: Claimant 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 must be submitted. If claimant is a business and is not incorporated, document(s) to verify the new address, such as utility bill, occupational license, or bank statements should be submitted. If incorporated, a copy of most recent filing with Sec of State (www.sunbiz.org), or filing that reflects address change should be submitted. New Address: City: State: Zip: Phone #: Please return this form along with the supporting documentation to: The Department of Financial Services, Division of Rehabilitation and Liquidation, Attention: Claims Dept – Change of Address, 2020 Capital Circle, 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 Claimant Address Change Only Request Instructions Support documents, as specified below, must accompany your request. The Receiver reserves the right to validate any address change request received and may request additional information from you. Please contact us if you have questions by clicking on the “Contact Us Form” at our website’s www.myfloridacfo.com/receiver navigation pane or you may call Consumer Services at 800-882-3054. Please complete the Claimant Address Change Only Request Form and send it in with these documents: • If you are an individual: a copy of valid driver license, utility bill, passport, or other photographic legal identification document that contains the address you have entered on your form. • If you are an unincorporated business: a utility bill, an occupational license or bank statements that contain the address you have entered on your form. • If you are an incorporated business: a copy of most recent filing with Sec of State (www.sunbiz.org), or other filing that contains the address you have entered on your form.
© Copyright 2018 AnyForm