Notification of Changes for Business Entity
General Information
Business Entity Name:	SUMMIT AMERICA INSURANCE SERVICES, INC.
Incorporation / Formation Date:	06/15/2010
FEIN:	272874018
Ohio License Number:	41709
NPN:	15957176
DBA / Trade Name:
State of Domicile:	DE
County:	UNKNOWN
Business Address
Address 1:	9225 INDIAN CREEK PKWY STE 700
Address 2:
City:	OVERLAND PARK
State:	KS
Zip:	66210
Phone:	9259561639
Fax:	8168421352
Business Web Site Address:
Business Email Address:	COMPLIANCE@ASCENSIONINS.COM
Mailing Address
Address 1:	1277 TREAT BLVD., SUITE 400
Address 2:
City:	WALNUT CREEK
State:	CA
Zip:	94597
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
CAROLINE FLOREZ	RESPONSIBLE PRODUCER	5071637		YES	01-18-2016

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:	ELISA YU
Title:	CORPORATE LEGAL COUNSEL
Phone Number:	925-956-1639
Email Address:	COMPLIANCE@ASCENSIONINS.COM