Notification of Changes for Business Entity
General Information
Business Entity Name:	SUNUP INSURANCE SERVICES INC
Incorporation / Formation Date:
FEIN:	811365745
Ohio License Number:	1139188
NPN:	17863675
DBA / Trade Name:
State of Domicile:	NC
County:	DAVIE
Business Address
Address 1:	152 E KINDERTON WAY STE 201
Address 2:
City:	BERMUDA RUN
State:	NC
Zip:	27006
Phone:	(704) 213-9700
Fax:	(713) 244-5918
Business Web Site Address:
Business Email Address:	SUPPORT@SUNUPINSURANCE.COM
Mailing Address
Address 1:	152 E KINDERTON WAY STE 201
Address 2:
City:	BERMUDA RUN
State:	NC
Zip:	27006
Indicate the type of change you are seeking
Address Change:	YES
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

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:	VICKI STEVENS
Title:	LICENSING ADMINISTRATOR
Phone Number:	(812) 886-0191
Email Address:	VJSTEVENS@SUPPORTIVEIS.COM