Notification of Changes for Business Entity
General Information
Business Entity Name:	PREMIERE SENIOR INSURANCE SERVICES, INC
Incorporation / Formation Date:
FEIN:	320043220
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	CLERMONT
Business Address
Address 1:	2234 BAUER RD
Address 2:	SUITE B2
City:	BATAVIA
State:	OH
Zip:	45103
Phone:	5139434560
Fax:
Business Web Site Address:
Business Email Address:	PSISINFO1@GMAIL.COM
Mailing Address
Address 1:	PO BOX 343
Address 2:
City:	BATAVIA
State:	OH
Zip:	45103
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:	PREMIERE INSURANCE SERVICES
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
MARK KOFALT

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:	MARK KOFALT
Title:	PRESIDENT
Phone Number:	5139434560
Email Address:	PSISINFO1@GMAIL.COM