| Notification of Changes for Business Entity |
| General Information | |
| Business Entity Name: | PROVISION BROKERAGE |
| Incorporation / Formation Date: | 05/16/2012 |
| FEIN: | 455304836 |
| Ohio License Number: | 969845 |
| NPN: | 16700708 |
| DBA / Trade Name: | |
| State of Domicile: | TX |
| County: | DALLAS |
| Business Address | |
| Address 1: | 12222 MERIT DR. |
| Address 2: | SUITE 1010 |
| City: | DALLAS |
| State: | TX |
| Zip: | 75251 |
| Phone: | 8887767590 |
| Fax: | |
| Business Web Site Address: | |
| Business Email Address: | |
| Mailing Address | |
| Address 1: | 12222 MERIT DR. |
| Address 2: | SUITE 1010 |
| City: | DALLAS |
| State: | TX |
| Zip: | 75251 |
| | |
| 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 |
| | |
| 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? |
| 3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement | |