Notification of Changes for Business Entity
General Information
Business Entity Name:	DEEP SOUTH SURPLUS INC.
Incorporation / Formation Date:
FEIN:	720900810
Ohio License Number:
NPN:	3471141
DBA / Trade Name:
State of Domicile:	LA
County:	SHREVEPORT
Business Address
Address 1:	701 B STREET 6TH FLOOR
Address 2:
City:	SAN DIEGO
State:	CA
Zip:	92101
Phone:	2144934228
Fax:
Business Web Site Address:
Business Email Address:	AGENCYLICENSING@DEEP-SOUTH.COM
Mailing Address
Address 1:	701 B STREET 6TH FLOOR
Address 2:
City:	SAN DIEGO
State:	CA
Zip:	92101
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
MICHELLE LOWRY	DRLP	13101048		YES	12/31/2016
TYLER HAMILTON	DRLP	10911197	YES		01/01/2017

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)	NO
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?	NO
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:	NANCY SELF
Title:	AVP
Phone Number:	2144934228
Email Address:	NSELF@DEEP-SOUTH.COM