Notification of Changes for Business Entity
General Information
Business Entity Name:	PROSPECT GENERAL INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	474773135
Ohio License Number:	1136367, 1138284
NPN:	17705080
DBA / Trade Name:
State of Domicile:	CA
County:	SAN DIEGO
Business Address
Address 1:	7979 IVANHOE AVENUE, SUITE 555
Address 2:
City:	LA JOLLA
State:	CA
Zip:	92037
Phone:	619-567-5360
Fax:
Business Web Site Address:
Business Email Address:	GMD@PROSPECTGENERAL.COM
Mailing Address
Address 1:	7979 IVANHOE AVENUE, SUITE 555
Address 2:
City:	LA JOLLA
State:	CA
Zip:	92037
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
GRAHAM DORAN	RDA	538788598	YES		12/19/2018
RYAN O'CONNOR	RDA	602032873		YES	12/19/2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
JANIE SELLERS

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:	JANIE SELLERS
Title:	COMPLIANCE SPECIALIST
Phone Number:	2547296136
Email Address:	JSELLERS@ILSAINC.COM