Notification of Changes for Business Entity
General Information
Business Entity Name:	TRUBRIDGE INC
Incorporation / Formation Date:
FEIN:	26-0641675
Ohio License Number:	1022490
NPN:	12780560
DBA / Trade Name:
State of Domicile:	OH
County:	STARK
Business Address
Address 1:	219 E MAPLE ST
Address 2:	SUITE 3000
City:	NORTH CANTON
State:	OH
Zip:	44720
Phone:	201-552-5816
Fax:
Business Web Site Address:
Business Email Address:	LICENSING@TRUBRIDGEINC.COM
Mailing Address
Address 1:	219 E MAPLE ST
Address 2:	SUITE 3000
City:	NORTH CANTON
State:	OH
Zip:	44720
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
JOHN JORDAN	AGENT	18084954	YES		09/29/16
JENNA KELLY	AGENT	18051014	YES		09/29/16
ALIVIA KEMP	AGENT	18008706	YES		09/29/16
ALLISON KING	AGENT	18042247	YES		09/29/16
HEATHER KOELBLE	AGENT	18082562	YES		09/29/16
CHRISTINA LIJOI	AGENT	18042206	YES		09/29/16
ELIZABETH LIPTAK	AGENT	18042166	YES		09/29/16
TISHA LYNN	AGENT	18011309	YES		09/29/16
TRACY MATTISON	AGENT	18085008	YES		09/29/16
MICHELLE MAY	AGENT	18081029	YES		09/29/16
KIERSTEN MICK	AGENT	18081108	YES		09/29/16
GEORGE MILNES	AGENT	18011248	YES		09/29/16
STASHIA NOLAND	AGENT	18042306	YES		09/29/16
AMANDA OVERHOLT	AGENT	18076150	YES		09/29/16
TIFFANEY OWENS	AGENT	17955907	YES		09/29/16

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
BRANDI PERKINS	AGENT	18051008	YES		09/29/16
ALLISON POLLARD	AGENT	17633185	YES		09/29/16
GREGORY PROSSER	AGENT	3241847	YES		09/29/16
RAVEN REAGON	AGENT	18050306	YES		09/29/16
ORA RICHARDS	AGENT	18008400	YES		09/29/16
SELENA RODRIGUEZ	AGENT	18082629	YES		09/29/16
MICHELLE RUE	AGENT	4950318	YES		09/29/16
DENNIS SARBAK	AGENT	3236005	YES		09/29/16
KRYSTAL SCHMALZA	AGENT	18011229	YES		09/29/16
NATASHA SMITH	AGENT	18074256	YES		09/29/16

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:	CINDY MOLESKY
Title:	LICENSING/CONTRACTING COORDINATOR
Phone Number:	201-552-5816
Email Address:	LICENSING@TRUBRIDGEINC.COM