| Notification of Changes for Business Entity |
| General Information | |
| Business Entity Name: | ASCENSION INSURANCE AGENCY, INC. |
| Incorporation / Formation Date: | 10/31/2008 |
| FEIN: | 26-3652075 |
| Ohio License Number: | 38866 |
| NPN: | 12351042 |
| DBA / Trade Name: | ASCENSION BENEFITS & INSURANCE SOLUTIONS (PLEASE REMOVE) |
| State of Domicile: | DE |
| County: | NEW CASTLE |
| Business Address | |
| Address 1: | 5821 FAIRVIEW ROAD, SUITE 500 |
| Address 2: | |
| City: | CHARLOTTE |
| State: | NC |
| Zip: | 28209 |
| Phone: | 925-956-1639 |
| Fax: | 925-945-7306 |
| Business Web Site Address: | |
| Business Email Address: | ASCENSION@3HCS.COM |
| Mailing Address | |
| Address 1: | 1277 TREAT BOULEVARD, SUITE 400 |
| Address 2: | |
| City: | WALNUT CREEK |
| State: | CA |
| Zip: | 94597 |
| | |
| Indicate the type of change you are seeking |
| Address Change: | NO |
| Business Entity Name Change: | YES | Old Business Entity Name: | RELATION (CON'T NEXT 2 LINES) |
| New DBA/Trade Name: | NO | New DBA/Trade Name: | INSURANCE SERVICES OF NORTH |
| Amend DBA/Trade Name: | NO | Old DBA/Trade Name: | CAROLINA, INC. |
| 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) |
| 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 | |