Notification of Changes for Business Entity
General Information
Business Entity Name:	PILLAR INSURANCE SERVICES LLC
Incorporation / Formation Date:	08/25/2011
FEIN:	45-3216205
Ohio License Number:	962726
NPN:	16386213
DBA / Trade Name:	PILLAR MN INSURANCE SERVICES
State of Domicile:	MN
County:	DOUGLAS
Business Address
Address 1:	1311 BROADWAY STREET
Address 2:
City:	ALEXANDRIA
State:	MN
Zip:	56308
Phone:	3207593552
Fax:
Business Web Site Address:
Business Email Address:	ALLYSON@GOGC.COM
Mailing Address
Address 1:	1311 BROADWAY STREET
Address 2:
City:	ALEXANDRIA
State:	MN
Zip:	56308
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:	PILLAR MN 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

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:	ALLYSON RADACH
Title:	INSURANCE ADVISOR
Phone Number:	3207593552
Email Address:	ALLYSON@GOGC.COM