Notification of Changes for Business Entity
General Information
Business Entity Name:	EMBARK GENERAL INSURANCE AGENCY, LLC
Incorporation / Formation Date:
FEIN:	830707283
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	DOVER
Business Address
Address 1:	400 NORTHRIDGE ROAD
Address 2:	SUITE 800
City:	SANDY SPRINGS
State:	GA
Zip:	30350
Phone:	770-234-3643
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 105301
Address 2:
City:	ALTANTA
State:	GA
Zip:	30348
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:	JACK GENOVESE
Title:	TREASURER
Phone Number:	770-234-3643
Email Address:	JGENOVESE@EMBARKGENERAL.COM