Notification of Changes for Business Entity
General Information
Business Entity Name:	SECURITIES AMERICA
Incorporation / Formation Date:
FEIN:	112551174
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	NE
County:	SARPY
Business Address
Address 1:	12325 PORT GRACE BLVD
Address 2:
City:	LAVISTA
State:	NE
Zip:	68128
Phone:	800-747-6111
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 460001
Address 2:
City:	PAPILLION
State:	NE
Zip:	68046
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
MICHAEL BOBOWSKI	PRODUCER	12297256	YES		03/23/2016
MARK PFISTER	PRODUCER	2779847	YES		03/23/2016
ROBERT ROSSI	PRODUCER	3193419	YES		03/23/2016
DAKOTA DURBIN	PRODUCER	17123179		YES	03/23/2016
JESSICA SILVER	PRODUCER	15543953		YES	03/23/2016
THOMAS TAPLINGER	PRODUCER	435147		YES	03/23/2016

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	THERESA HOMECILLO
Title:	MANAGER-LICENSING & REGISTRATION
Phone Number:	800-747-6111
Email Address:	LICENSINGNEWREQUESTS@SAIONLINE.COM