Notification of Changes for Business Entity
General Information
Business Entity Name:	CMS NATIONAL
Incorporation / Formation Date:
FEIN:	201856127
Ohio License Number:	34982
NPN:	8796083
DBA / Trade Name:
State of Domicile:	OH
County:	NEW PORT BEACH
Business Address
Address 1:	4695 MACARTHUR COURT SUITE 400
Address 2:
City:	NEW PORT BEACH
State:	CA
Zip:	92660
Phone:	8775674267
Fax:	9497941886
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	4695 MACARTHUR COURT SUITE 400
Address 2:
City:	NEWPORT BEACH
State:	CA
Zip:	92660
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
MICHAEL ROTHMAN	PRODUCER	1430430	YES		11/03/2015

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:	CHRISTY KRICK
Title:	LICENSING ADMINISTRATOR
Phone Number:	8124942472
Email Address:	CKRICK@SUPPORTIVEIS.COM