Notification of Changes for Business Entity
General Information
Business Entity Name:	CARE PROVIDERS INSURANCE SERVICES LLC
Incorporation / Formation Date:
FEIN:	830348144
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	CASS
Business Address
Address 1:	16301 QUORUM DR STE 100A
Address 2:
City:	ADDISON
State:	TX
Zip:	75001
Phone:	8009709778
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	555 NORTH LANE
Address 2:	STE 6060
City:	CONSHOHOCKEN
State:	PA
Zip:	19428
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:	HEACOCK CLASSIC
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:	JANET MARMAN
Title:	COMPLIANCE MANAGER
Phone Number:	9545076580
Email Address:	JANETMARMAN@NSMINC.COM