Notification of Changes for Business Entity
General Information
Business Entity Name:	ASURIOIN INSURANCE SERVICES, INC.
Incorporation / Formation Date:
FEIN:	62-1463468
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	TN
County:	DAVIDSON
Business Address
Address 1:	648 GRASSMERE PARK
Address 2:	STE. 100
City:	NASHVILLE
State:	TN
Zip:	37211
Phone:	615-762-1152
Fax:
Business Web Site Address:
Business Email Address:	LICENSING@ASURION.COM
Mailing Address
Address 1:	648 GRASSMERE PARK
Address 2:	STE. 100
City:	NASHVILLE
State:	TN
Zip:	37211
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
ELLA WASHINGTON-TANKSON	PRODUCER	15258816		YES	3/30/2018
MARSHA MCFARLAND	PRODUCER	10660758		YES	3/30/2018

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:	ANDY BUQUET
Title:	LICENSING COORDINATOR
Phone Number:	6157621152
Email Address:	LICENSING@ASURION.COM