Information Update Request
For Address and/or Name Changes
Enter your Name (before change, if any)
*
First Name
Last Name
Enter your Email Address
*
example@example.com
What Company do you work for?
*
Enter Company Name
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Next
What Information do you wish to update?
Please Select
Address Change
Name Change
Both Address & Name Change
Select
Back
Next
Please Enter New Name
First Name
Middle Name
Last Name
Suffix
Please upload Name Change documentation
Browse Files
Drag and drop files here
Choose a file
Acceptable documentation: Marriage License, Divorce Decree, Social Security Card, Drivers License
Cancel
of
Back
Next
Enter New Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Will you need you need replacement insurance membership cards?
Please Select
Yes
No
Back
Next
By signing, you authorize KIAA to make the changes you entered.
Submit
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