Notification of Changes for Business Entity
General Information
Business Entity Name:	CROWN ATLANTIC INSURANCE, LLC
Incorporation / Formation Date:
FEIN:	46-3583270
Ohio License Number:	1011322
NPN:	17063026
DBA / Trade Name:
State of Domicile:	FL
County:	FLORIDA
Business Address
Address 1:	750 PARK OF COMMERCE DR, SUITE 100
Address 2:
City:	BOCA RATON
State:	FL
Zip:	33487
Phone:	5619943111
Fax:
Business Web Site Address:
Business Email Address:	AAZAR@CROWNATLANTIC.COM
Mailing Address
Address 1:	750 PARK OF COMMERCE DR, SUITE 100
Address 2:
City:	BOCA RATON
State:	FL
Zip:	33487
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	JOSEPH D. STARK
Title:	CEO
Phone Number:	561-994-311
Email Address:	JSTARK@CROWNATLANTIC.COM