Claimant Address Change Only Request Form

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.