Notification of Changes for Business Entity
General Information
Business Entity Name:	VIZIENT INSURANCE SERVICES
Incorporation / Formation Date:
FEIN:	81-1160673
Ohio License Number:	1136286
NPN:	18173167
DBA / Trade Name:
State of Domicile:	TX
County:	DALLAS
Business Address
Address 1:	290 E JOHN CARPENTER FREEWAY
Address 2:
City:	IRVING
State:	TX
Zip:	75062
Phone:	9728300025
Fax:
Business Web Site Address:
Business Email Address:	BEN.CARROLL@VIZIENTINC.COM
Mailing Address
Address 1:	290 E JOHN CARPENTER FREEWAY
Address 2:
City:	IRVING
State:	TX
Zip:	75062
Indicate the type of change you are seeking
Address Change:	NO
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
JAMON HERNDON	SR DIRECTOR	3540621	YES		05/30/2017
BECKY VANN	SR DIRECTOR	8330387	YES		05/30/2017
TARA KING	ACCOUNT EXECUTIVE	10028959	YES		05/30/2017

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:	JEFF ANDERSEN
Title:	DIRECTOR
Phone Number:	913-319-6203
Email Address:	JEFF.ANDERSEN@VIZIENTINC.COM