Notification of Changes for Business Entity
General Information  
Business Entity Name: ACRISURE, LLC
Incorporation / Formation Date:  
FEIN: 26-3554645
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: MI
County: MI
Business Address  
Address 1: 5664 PRAIRIE CREEK DR SE
Address 2:  
City: CALEDONIA
State: MI
Zip: 49316
Phone: 6165411326
Fax:  
Business Web Site Address:  
Business Email Address: INSURANCELICENSING@ACRISURE.COM
Mailing Address  
Address 1: 5664 PRAIRIE CREEK DR SE
Address 2:  
City: CALEDONIA
State: MI
Zip: 49316
   
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
JEROME ALLAN TEPPER PRODUCER 59045 YES   9/29/17
TRAMMELL L NORRIS PRODUCER 75725 YES   9/29/17
DANIEL RAY SHUBERT PRODUCER 677848 YES   9/29/17
CHRISTOPHER VINCENT PRESTERA PRODUCER 1102034 YES   9/29/17
PHILLIP DAVID GREER PRODUCER 1059710 YES   9/29/17
DELPHINE(BUENTELLO) HUDDELSTON PRODUCER 1057848   YES 9/29/17
           
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: TASHA WESSEL
Title: LICENSING ASSISTANT
Phone Number: 6165411326
Email Address: INSURANCELICENSING@ACRISURE.COM