Notification of Changes for Business Entity
General Information
Business Entity Name:	FIRST CHOICE MED LLC
Incorporation / Formation Date:
FEIN:	81-2461499
Ohio License Number:	1192513
NPN:	17932069
DBA / Trade Name:
State of Domicile:	FL
County:	BROWARD
Business Address
Address 1:	1600 S. FEDERAL HWY
Address 2:	SUITE 811
City:	POMPANO BEACH
State:	FL
Zip:	33062
Phone:	866-205-3158
Fax:
Business Web Site Address:
Business Email Address:	LICENSING@AHGINSURE.COM
Mailing Address
Address 1:	P.O. BOX 1619
Address 2:
City:	POMPANO BEACH
State:	FL
Zip:	33061
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:	DANIEL HELINSKI
Title:	OWNER
Phone Number:	866-205-3158
Email Address:	LICENSING@AHGINSURE.COM