Notification of Changes for Business Entity
General Information
Business Entity Name:	IIAT SERVICES MGA, INC.
Incorporation / Formation Date:
FEIN:	472188002
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	TRAVIS
Business Address
Address 1:	1115 SAN JACINTO BLVD. STE 100
Address 2:
City:	AUSTIN
State:	TX
Zip:	78701
Phone:	2149971694
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 684487
Address 2:
City:	AUSTIN
State:	TX
Zip:	78768
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
JERRY MACKEY	PRESIDENT	488663560		YES	1/9/2017
MELISSA REED	RDA/VICE PRESIDENT /SECRETARY	1056947		YES	1/9/2017
APRIL MOESER	EXECUTIVE VICE PRESIDENT/RDA	1133007	YES		1/9/2017

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:	KYM CRAVER
Title:	LICENSING SPECIALIST
Phone Number:	254-729-6145
Email Address:	KCRAVER@ILSAINC.COM