Notification of Changes for Business Entity
General Information
Business Entity Name:	ASSURED NL INS SERVICES INC
Incorporation / Formation Date:
FEIN:	452712475
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	KY
County:	JEFFERSON
Business Address
Address 1:	2211 RIVER ROAD
Address 2:
City:	LOUISVILLE
State:	KY
Zip:	40206
Phone:	5022599240
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	5905 E GALBRAITH RD, STE 500
Address 2:
City:	CINCINNATI
State:	OH
Zip:	45236
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
JEROME TURNER	PRODUCER	16165535	YES		06/01/2017

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:	ERIC ANDERSON
Title:	RDA
Phone Number:	5022599240
Email Address:	KATHY.KELLEYSMITH@ASSUREDPTRNL.COM