Notification of Changes for Business Entity
General Information
Business Entity Name:	ETHOS SPECIALTY INSURANCE SERVICES, LLC.
Incorporation / Formation Date:	08/07/2017
FEIN:	822797880
Ohio License Number:	1171648
NPN:	18559234
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	225 BROADHOLLOW ROAD, SUITE 405
Address 2:
City:	MELVILLE
State:	NY
Zip:	11747
Phone:	(631)794-0300
Fax:
Business Web Site Address:	WWW.ETHOSUM.COM
Business Email Address:
Mailing Address
Address 1:	225 BROADHOLLOW ROAD, SUITE 405
Address 2:
City:	MELVILLE
State:	NY
Zip:	11747
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:	JUDY HO
Title:	ADMINISTRATIVE COORDINATOR
Phone Number:	(631)794-0308
Email Address:	JUDY.HO@ETHOSUM.COM