Notification of Changes for Business Entity
General Information
Business Entity Name:	SENIORS UNITED INSURANCE AGENCY, INC
Incorporation / Formation Date:
FEIN:	36-4824727
Ohio License Number:	1096133
NPN:	17830119
DBA / Trade Name:
State of Domicile:	CA
County:	LOS ANGELES
Business Address
Address 1:	4640 ADMIRALTY WAY
Address 2:	SUITE 200
City:	MARINA DEL REY
State:	CA
Zip:	90292
Phone:	310-405-0835
Fax:
Business Web Site Address:
Business Email Address:	HANK.HATTEMER@NEILSONFS.COM
Mailing Address
Address 1:	4640 ADMIRALTY WAY
Address 2:	SUITE 200
City:	MARINA DEL REY
State:	CA
Zip:	90292
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
CHRIS SAMPSON	AGENT	17856020		YES	9/28/2016
DANIEL VICHET PLOM	MANAGER	17839357		YES	9/28/2016
EDWARD ADOLPH SCHILLING	AGENT	14090942		YES	9/28/2016
GLENN ROY DIECEDUE JR	AGENT	4759391		YES	9/28/2016
HUGH JOSEPH MCADOREY	SECRETARY	17790918		YES	9/28/2016
PRISCILLA ESTHER SIAS	AGENT	17843584		YES	9/28/2016
GREGORY CLARK	AGENT	17991137	YES		9/28/2016
GEORGE GUMBS	AGENT	17620939	YES		9/28/2016
STEPHANIE HEHIR	AGENT	17983939	YES		9/28/2016
MATTHEW JENKINS	AGENT	12871477	YES		9/28/2016
GLENMORE JOHNSON	AGENT	17995351	YES		9/28/2016
SHANE LEECESNE	AGENT	17329343	YES		9/28/2016
GARY MATATOV	AGENT	16798019	YES		9/28/2016
RYAN MATTINGLY	AGENT	17834313	YES		9/28/2016
STEVEN PETRUZELLO	AGENT	17955078	YES		9/28/2016

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:	HENRY HATTEMER
Title:	RDA
Phone Number:	310-4050835
Email Address:	HANK.HATTEMER@NEILSONFS.COM