Notification of Changes for Business Entity
General Information
Business Entity Name:	RELATION INSURANCE SERVICES OF NORTH CAROLINA, INC.
Incorporation / Formation Date:	10/31/2008
FEIN:	26-3652075
Ohio License Number:	38866
NPN:	12351042
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	11215 NORTH COMMUNITY HOUSE ROAD, SUITE 100
Address 2:
City:	CHARLOTTE
State:	NC
Zip:	28277
Phone:	925-956-1639
Fax:	925-945-7306
Business Web Site Address:
Business Email Address:	RELATIONDOI@3HCS.COM
Mailing Address
Address 1:	1277 TREAT BOULEVARD, SUITE 400
Address 2:
City:	WALNUT CREEK
State:	CA
Zip:	94597
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:	EDWARD NATHAN PAGE
Title:	PRESIDENT
Phone Number:	518-583-0639 EXT. 114
Email Address:	RELATIONDOI@3HCS.COM