Notification of Changes for Business Entity
General Information
Business Entity Name:	CLARK CONSULTING LLC
Incorporation / Formation Date:
FEIN:	522103928
Ohio License Number:	23876
NPN:	2214982
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	C/O CORPORATE SERVICE COMPANY
Address 2:	2711 CENTERVILLE RD
City:	WILMINGTON
State:	DE
Zip:	19800
Phone:	8006279800
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	C/O JOANNA COX
Address 2:	1814 ST ANDREWS RD
City:	GREENSBORO
State:	NC
Zip:	27408
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
TRACI BRUNER COOK	RDA	7436605		YES	01162017
JOANNA COX	RDA	8376144	YES		01162017

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)	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 REP
Phone Number:	8124942392
Email Address:	CWMCKINNEY@SUPPORTIVEIS.COM