Notification of Changes for Business Entity
General Information
Business Entity Name:	MII LIFE, INCORPORATED
Incorporation / Formation Date:
FEIN:	41-60919132
Ohio License Number:	1135664
NPN:
DBA / Trade Name:
State of Domicile:	MN
County:	DAKOTA
Business Address
Address 1:	1750 YANKEE DOODLE RD.
Address 2:
City:	EAGAN
State:	MN
Zip:	55121
Phone:	855-363-2583
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 64193
Address 2:
City:	ST. PAUL
State:	MN
Zip:	55164
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	YES	New DBA/Trade Name:	FURTHER
Amend DBA/Trade Name:	YES	Old DBA/Trade Name:	SELECTACCOUNT
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:	MADELINE BARDOLF
Title:	CONSULTANT
Phone Number:	850-294-1928
Email Address:	MADELINE@PATTONCOMPLIANCE.COM