Notification of Changes for Business Entity
General Information
Business Entity Name:	PARAGON INSURANCE HOLDINGS LLC
Incorporation / Formation Date:
FEIN:	464950868
Ohio License Number:	1024543
NPN:	17217583
DBA / Trade Name:
State of Domicile:	OH
County:	AVON
Business Address
Address 1:	45 NOD RD
Address 2:	SUITE 1
City:	AVON
State:	CT
Zip:	06001
Phone:	8602661462
Fax:	8605164876
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	45 NOD RD
Address 2:	SUITE 1
City:	AVON
State:	CT
Zip:	06001
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
KENNETH POPELESKI	CFO	047763820	YES		031616

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:	CHRISTY KRICK
Title:	LICENSING ADMINISTRATOR
Phone Number:	8124942472
Email Address:	CKRICK@SUPPORTIVEIS.COM