Address Change Form

Pennsylvania Public Utility CommissionBureau of Technical Utility Services

NOTIFICATION OF ADDRESS CHANGE FOR CERTIFICATE,
PERMIT, AND BROKERAGE LICENSE HOLDERS

COMPANY NAME _________________________________________________ A-_____________________

TRADE NAME ____________________________________________________________________________

OLD

ADDRESS _________________________________________________________________________________

_________________________________________________________________________________

NEW

MAILING ________________________________________________________________________________

ADDRESS

________________________________________________________________________________

TELEPHONE# _____________________________________________________________________________

AUTHORIZED SIGNATURE ________________________________________________________________

PLEASE PRINT NAME _____________________________________________________________________

DATE ____________________________________________________________________________________

(PLEASE ADVISE INSURANCE COMPANY OF THE ABOVE CHANGE OF ADDRESS)

PLEASE RETURN TO:

PENNSYLVANIA PUBLIC UTILITY COMMISSION

SECRETARY’S BUREAU

P.O. BOX 3265

HARRISBURG, PA 17105-3265

(Rev. 11/10/11)