Notification of Changes for Business Entity
General Information
Business Entity Name:	TRUBRIDGE
Incorporation / Formation Date:
FEIN:	260641675
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	STARK
Business Address
Address 1:	219 E MAPLE ST
Address 2:	SUITE 3000
City:	NORTH CANTON
State:	OH
Zip:	44720
Phone:	234-401-1597
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	219 E MAPLE ST
Address 2:	SUITE 3000
City:	NORTH CANTON
State:	OH
Zip:	44720
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
AKEVA MCKEAVER	AGENT	18122787		YES	8/8/2018
ALANNI HARRELL	AGENT	18074179		YES	8/8/2018
ALEXANDRA CAVINESS	AGENT	18082931		YES	8/8/2018
ASHTON CROOKS	AGENT	18427392		YES	8/8/2018
AUTUMN WILKERSON	AGENT	18063617		YES	8/8/2018
BARRY LANDWERT	AGENT	17394402		YES	8/8/2018
BRIAN BROWN	AGENT	17952350		YES	8/8/2018
CARA GASSMAN	AGENT	17702972		YES	8/8/2018
CARLA PROUDFOOT	AGENT	17703894		YES	8/8/2018
CHARMAINE DAVIS	AGENT	18053394		YES	8/8/2018
CHRISTINA LIJOI	AGENT	18042206		YES	8/8/2018
CLAIR WAUCAUSH	AGENT	18035566		YES	8/8/2018
COURTNEY FARNELL	AGENT	16405855		YES	8/8/2018

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:	NICOLE GATES
Title:	LICENSING SPECIALIST
Phone Number:	304-929-3257
Email Address:	NICOLE.GATES@TZINSURANCE.COM