Notification of Changes for Business Entity
General Information
Business Entity Name:	RISK PLACEMENT SERVICES, INC.
Incorporation / Formation Date:	10/05/1979
FEIN:	36-3110841
Ohio License Number:	23614 & 29703
NPN:	2101845
DBA / Trade Name:
State of Domicile:	IL
County:	COOK
Business Address
Address 1:	2850 GOLF ROAD
Address 2:
City:	ROLLING MEADOWS
State:	IL
Zip:	60008
Phone:	630-773-3800
Fax:
Business Web Site Address:	WWW.RPSINS.COM
Business Email Address:	SHARON_ARNOLD@RPSINS.COM
Mailing Address
Address 1:	2850 GOLF ROAD
Address 2:
City:	ROLLING MEADOWS
State:	IL
Zip:	60008
Indicate the type of change you are seeking
Address Change:	YES
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:	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:	SHARON ARNOLD
Title:	LICENSING MANAGER
Phone Number:	630-285-4236
Email Address:	SHARON_ARNOLD@RPSINS.COM