Notification of Changes for Business Entity
General Information
Business Entity Name:	ACRISURE, LLC
Incorporation / Formation Date:
FEIN:	26-3554645
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	MI
County:	KENT
Business Address
Address 1:	5664 PRAIRIE CREEK DR
Address 2:
City:	CALEDONIA
State:	MI
Zip:	49316
Phone:	8007480351
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	5664 PRAIRIE CREEK DR
Address 2:
City:	CALEDONIA
State:	MI
Zip:	49316
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
ANGELA KIESELAT	PRODUCER	17171285	YES		10/15/2018

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:	KRISTEN WRIGHT
Title:	REGED LICENSING SPECIALIST
Phone Number:
Email Address: