Notification of Changes for Business Entity
General Information
Business Entity Name:	KEYSTONE RISK MANAGERS LLC
Incorporation / Formation Date:	04/16/2001
FEIN:	233080706
Ohio License Number:	36842
NPN:	6914448
DBA / Trade Name:
State of Domicile:	PA
County:	NORTHUMBERLAND
Business Address
Address 1:	1995 POINT TOWNSHIP DR.
Address 2:
City:	NORTHUMBERLAND
State:	PA
Zip:	17857
Phone:	570-473-2142
Fax:
Business Web Site Address:
Business Email Address:	GMONTAGNA@KEYSTONEINSGRP.COM
Mailing Address
Address 1:	1995 POINT TOWNSHIP DR.
Address 2:
City:	NORTHUMBERLAND
State:	PA
Zip:	17857
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
LEA ANN HAWK	COO	8171749	YES		4/25/2017
LEA ANN HAWK	RDA	8171749	YES		4/25/2017

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:	LEA ANN HAWK
Title:	COO AND RDA
Phone Number:	570-473-2142
Email Address:	GMONTAGNA@KEYSTONEINSGRP.COM