Notification of Changes for Business Entity
General Information  
Business Entity Name: RENAISSANCE ALLIANCE INSURANCE SERVICES, LLC
Incorporation / Formation Date:  
FEIN: 043456048
Ohio License Number: 34309
NPN: 3748814
DBA / Trade Name:  
State of Domicile: MA
County: NORFOLK
Business Address  
Address 1: 981 WORCESTER STREET
Address 2:  
City: WELLESLEY
State: MA
Zip: 02482
Phone: 7814319800
Fax:  
Business Web Site Address:  
Business Email Address: MARYLOU.FOSBERG@RENAISSANCEINS.COM
Mailing Address  
Address 1: 981 WORCESTER STREET
Address 2:  
City: WELLESLEY
State: MA
Zip: 02482
   
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
           
Members, Owners, Partners, Officers and Directors
Name Title Identifying # Add Delete Eff. Date
ROBERT GRUHL CFO & DIRECTOR 369-46-3778 YES   04/04/2018
KENN ALLEN DIRECTOR 296-46-2112 YES   04/04/2018
LYMAN BULLARD SECRETARY 025-36-3271 YES   04/04/2018
PATRICK MCDONALD DIRECTOR 039-48-9124 YES   04/04/52018
STEVEN BERRY DIRECTOR 083-60-5632 YES   04/04/2018
DOUGLAS BRIGGS DIRECTOR 026-44-2524 YES   04/04/2018
RONALD PETERS SR.VP 024-48-0385   YES 04/04/2018
JAMES MORAN VP, GENERAL COUNSEL 043-38-0920   YES 04/04/2018
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) NO
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? NO
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: JANIE SELLERS
Title: COMPLIANCE SPECIALIST
Phone Number: 2547296136
Email Address: JSELLERS@ILSAINC.COM