Notification of Changes for Business Entity
General Information
Business Entity Name:	PREFERRED REINSURANCE INTERMEDIARIES INC
Incorporation / Formation Date:
FEIN:	570870008
Ohio License Number:	1047546
NPN:
DBA / Trade Name:
State of Domicile:	SC
County:	COLUMBIA
Business Address
Address 1:	14 MONCKTON BLVD
Address 2:
City:	COLUMBIA
State:	SC
Zip:	29206
Phone:	8037904800
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	14 MONCKTON BLVD
Address 2:
City:	COLUMBIA
State:	SC
Zip:	29206
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
KAREN BASSO	SENIOR VP	098442773		YES	08/07/2017

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?	NO
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:	CANDY MCKINNEY
Title:	LICENSING REPRESENTATIVE
Phone Number:	8124942392
Email Address:	CWMCKINNEY@SUPPORTIVEIS.COM