LDTL REGISTRATION FORM

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LDTL Registration Form Filing Fee for Reinsurance Intermediary-$500

License Division Trade Name/Location Filing Fee for Other Agents or Entities-$50

Registration Form Make your check or money order payable to the Texas

Department of Insurance. All fees are nonrefundable and

nontransferable.

The LDTL form must be used in accordance with the provisions of 28 Texas Administrative Code, Section 19.902. It is

used to register assumed names and branch ofﬁce locations of currently licensed individuals and entities. It is also

used to change the ofﬁcial name of a currently licensed entity. Complete all information required on this form.

Incomplete forms will be returned unprocessed. This form must be typed or printed in ink. This form cannot be used

for any other purpose. (Note: To report a mailing address or business address change, please submit FIN533, Licensee

Name/Address Change Request form)

This LDTL form is submitted to register:

Assumed Name Branch Ofﬁce Location Ofﬁcial Name Change of Licensed Entity

1 INDIVIDUAL AGENT or ENTITY TDI LICENSE NUMBER ___________________________________________

Enter your Texas Department of Insurance (TDI) License Number in the space provided. The TDI License number is

shown on your current license. The license number should be that of the agent or entity registering an assumed name,

branch ofﬁce, or new entity name.

2 SOCIAL SECURITY NUMBER (SSN) OF INDIVIDUAL AGENT or FEDERAL EMPLOYER IDENTIFICATION

NUMBER (FEIN) OF ENTITY ______________________________________

Individual licensee–enter your SSN in the space provided. Entity licensee–enter the entity’s FEIN in the space

provided. Disclosure of Social Security Number is required by the Texas Family Code § 231.302.

3 NAME OF INDIVIDUAL AGENT or ENTITY

Print the exact name as shown on your license in the space provided. Do not print your assumed name or new entity

name in this space.

4 ASSUMED NAME or NEW NAME OF ENTITY __________________________________________________

To register an Assumed Name, enter the exact ASSUMED NAME as it is shown on the assumed name certiﬁcate.

To register an entity name change, enter the exact NEW NAME OF ENTITY as it is reﬂected in the entity’s ofﬁcial name

change document.

To register only an additional ofﬁce location, the agent or entity name should be the same as shown on the license.

Assumed Name means any name other than a true name or present legal name. You must attach a copy of an

Assumed Name Certiﬁcate that has been ﬁled with the County Clerk’s ofﬁce of the County in which the assumed name

will be utilized if the assumed name:

A. In the case of an individual, is a name that does not include the surname of the individual;

B. In the case of a partnership, is a name that does not include the surname or other legal name of each

partner;

C. In the case of an individual or partnership, is a name, including a surname, that suggests the existence of

additional owners by including words such as “Company”, “& Company”, “& Sons”, “& Associates”,

“Brothers” and similar words, but not words that merely describe the business or professional service being

conducted or rendered; and

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D. In the case of a limited partnership (LP), a corporation, a limited liability partnership (LLP), or a limited

liability company (LLC), any name other than the name stated in its certiﬁcate of formation or a comparable

document. A corporation, LP, LLP, or LLC may ﬁle a copy of assumed name certiﬁcate that has been ﬁled

with the Texas Secretary of State rather than the County Clerk.

New Name of Entity means the new ofﬁcial name of a currently licensed entity. You must attach a copy of the

Certiﬁcate of Amended Registration reﬂecting the ofﬁcial entity name change that was ﬁled with the Texas Secretary

of State’s ofﬁce or a copy of the Certiﬁcate of Name Change that was ﬁled with any other authorizing entity, or a

partnership must attach a copy of the ofﬁcial name change as shown in the amendments to the partnership

agreement.

5 ADDITIONAL BRANCH OFFICE OR PHYSICAL LOCATION ADDRESS OF LICENSED INDIVIDUAL AGENT or

ENTITY

______________________________________________________________________________________________

BUSINESS ADDRESS (PHYSICAL LOCATION REQUIRED; P.O. BOX NOT ACCEPTED)

________________________________________________ _________________ _____________________

CITY STATE ZIP CODE

Enter the physical location address of the additional ofﬁce location you are registering. Only a street or rural route

address will be accepted. If a post ofﬁce box address is entered, the form will be returned unprocessed. If you are

registering an additional assumed name, or new name of entity, then enter your agency’s current business address.

6 LICENSE REQUIRED TO ACT AS AGENT IN BRANCH OFFICE

Are you aware that although an assumed name or branch ofﬁce is registered with the Texas Department of Insurance,

only individuals holding active licenses may perform any acts of an agent in the registered assumed name and/or

branch ofﬁce? YES NO Refer to Texas Insurance Code, § 4001.003 for the deﬁnition of an agent.

7 HAVE YOU ATTACHED ALL REQUIRED DOCUMENTS? YES NO

Refer to question 4. Attach the assumed name certiﬁcate, if required. Each entity must attach (1) a copy of the

assumed name or a copy of the ofﬁcial document verifying the change of the entity’s name, and (2) adjustment on

ﬁnancial responsibility requirement by either an endorsement to its errors and omissions policy extending coverage

to include the assumed name and/or additional branch ofﬁce location or listing the new entity name as a named

insured on the policy. An entity that meets its ﬁnancial responsibility requirement with a bond must provide a rider

to the bond that reﬂects the entity’s new name. An entity changing its ofﬁcial name must attach its current license.

When TDI changes the name, you may print a copy of your license from the internet. Please see “How do I get a

copy of my license?” at www.tdi.texas.gov/licensing/agent/agfaq.html.

I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT AND THAT I HAVE ATTACHED ALL

INFORMATION REQUESTED. I FURTHER CERTIFY THAT I AM AWARE OF THE LICENSING PROVISIONS IN THE TEXAS

INSURANCE CODE AND THE PROVISIONS OF TITLE 28, TEXAS ADMINISTRATIVE CODE, SECTIONS 19.901 & 19.902,

WHICH RELATE TO THE REGISTRATION OF ASSUMED NAMES AND BRANCH OFFICES.

8 _______________________________________________________________

SIGNATURE OF INDIVIDUAL AGENT OR ENTITY’S OFFICER OR PARTNER

______________________

This form must be signed in ink by the individual agent or an ofﬁcer or partner of the entity ﬁling this registration. Print or type the full legal

name of the individual signing this form. The form must be dated.

9 ___________________________________________

EMAIL ADDRESS OF SIGNING INDIVIDUAL

DAYTIME PHONE NUMBER OF SIGNING INDIVIDUAL

Provide a contact phone number and email address where you may be reached.

Completed form with attachments and required fee must be mailed to:

Texas Department of Insurance - MC 107-A

P O Box 12069

Austin, Texas 78711-2069

If you have any questions or need further assistance, please call Customer Service at 512-676-6500.

_______________________________________________________________

PRINT FULL LEGAL NAME OF SIGNING AGENT, OFFICER OR PARTNER

__________________________________

DATE SIGNED