Notification of Changes for Business Entity
General Information
Business Entity Name:	CRUZ BAY PUBLISHING, INC
Incorporation / Formation Date:
FEIN:	320089097
Ohio License Number:	1035181
NPN:	17290610
DBA / Trade Name:
State of Domicile:	CO
County:	BOULDER
Business Address
Address 1:	2520 55TH ST, STE 210
Address 2:
City:	BOULDER
State:	CO
Zip:	80301
Phone:	8005046773
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 20634
Address 2:
City:	BOULDER
State:	CO
Zip:	80308
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:	TEACHERS PLUS INSURANCE SERVIC
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)	NO
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?	NO
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:	CANDY MCKINNEY
Title:	LICENSING REP
Phone Number:	8124942392
Email Address:	CWMCKINNEY@SUPPORTIVEIS.COM