Notification of Changes for Business Entity
General Information
Business Entity Name:	IS AGENCY, LLC
Incorporation / Formation Date:
FEIN:	271016516
Ohio License Number:	1018692
NPN:	15335684
DBA / Trade Name:
State of Domicile:	GA
County:	GWINNETT COUNTY
Business Address
Address 1:	2425 COMMERCE AVE NW STE 300
Address 2:
City:	DULUTH
State:	GA
Zip:	30096
Phone:	6789014046
Fax:	7702346057
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	2600 W GERONIMO PL STE 100
Address 2:
City:	CHANDLER
State:	AZ
Zip:	85224
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	IS AGENCY, INC.
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:	CHRISTY KRICK
Title:	LICENSING ADMINISTRATOR
Phone Number:	8124942472
Email Address:	CKRICK@SUPPORTIVEIS.COM