Notification of Changes for Business Entity
General Information
Business Entity Name:	ESURANCE INSURANCE SERVICES INC
Incorporation / Formation Date:
FEIN:	26-0034575
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	DOVER
Business Address
Address 1:	650 DAVIS STEET
Address 2:
City:	SAN FRANCISCO
State:	CA
Zip:	94111
Phone:	415-875-4500
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	650 DAVIS STREET
Address 2:
City:	SAN FRANCISCO
State:	CA
Zip:	94111
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
DARYL LEON WITHERSPOON	AGENT	16218275	YES		12/11/2018
JAMES HAROLD WHEELER	AGENT	18705334	YES		12/11/2018
JESSICA L. REED	AGENT	18989272	YES		12/11/2018
ZACKARY N. RAPLEE	AGENT	18988074	YES		12/11/2018
DAVID BRUCE POWERS	AGENT	15438134	YES		12/11/2018
ANDRES H. PEREZ	AGENT	18988144	YES		12/11/2018
JAMES MATTHEW MOORE	AGENT	18988204	YES		12/11/2018
FREDIANA LISETTE LOPEZ	AGENT	18988127	YES		12/11/2018
CHELSEA ELIZABETH HEERS	AGENT	18988193	YES		12/11/2018
TYLER REIS HAIGLER	AGENT	18988208	YES		12/11/2018
AMANDA KELLY BRYANT	AGENT	18988200	YES		12/11/2018
MICHAEL EDWARD BASH	AGENT	18988184	YES		12/11/2018
TEDDY LEE ANDERSON	AGENT	18988150	YES		12/11/2018

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:	JACQUELYN MATSON
Title:	LICENSING ADMIN
Phone Number:	916-625-3674
Email Address:	LICENSING@CENTRAL.ESURANCE.COM