Notification of Changes for Business Entity
General Information
Business Entity Name:	INSTACOVER, LLC
Incorporation / Formation Date:
FEIN:	454039195
Ohio License Number:	974751
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	KING
Business Address
Address 1:	17 CENTRAL WAY
Address 2:
City:	KIRKLAND
State:	WA
Zip:	98033
Phone:	866-928-9180
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	17 CENTRAL WAY
Address 2:
City:	KIRKLAND
State:	WA
Zip:	98033
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
AMY KNEELAND	RDA	18176868	YES		03/10/2017

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)	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:	APRIL EATON
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-886-0191
Email Address:	ADEATON@SUPPORTIVEIS.COM