| Notification of Changes for Business Entity |
| General Information | |
| Business Entity Name: | MEDICAL PROTECTIVE INSURANCE SERVICES, INC |
| Incorporation / Formation Date: | 10/151987 |
| FEIN: | 35-1721132 |
| Ohio License Number: | 29775 |
| NPN: | 663264 |
| DBA / Trade Name: | |
| State of Domicile: | IN |
| County: | ALLEN |
| Business Address | |
| Address 1: | 5814 REED ROAD |
| Address 2: | |
| City: | FORT WAYNE |
| State: | IN |
| Zip: | 46835 |
| Phone: | 800-463-3776 |
| Fax: | |
| Business Web Site Address: | MEDPRO.COM |
| Business Email Address: | MEDPROLICENSING@MEDPRO.COM |
| Mailing Address | |
| Address 1: | 5814 REED ROAD |
| Address 2: | |
| City: | FORT WAYNE |
| State: | IN |
| Zip: | 46835 |
| | |
| 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 |
| | |
| 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 | |