Notification of Changes for Business Entity
General Information
Business Entity Name:	BUILDERS & TRADESMEN'S INS SERVICES INC
Incorporation / Formation Date:
FEIN:	26-0131681
Ohio License Number:
NPN:	8756830
DBA / Trade Name:
State of Domicile:	CA
County:	PLACER
Business Address
Address 1:	6610 SIERRA COLLEGE BLVD
Address 2:
City:	ROCKLIN
State:	CA
Zip:	95677
Phone:	860-571-3104
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	400 EXECUTIVE BLVD 4TH FLOOR
Address 2:
City:	SOUTHINGTON
State:	CT
Zip:	06489
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
MICHAEL T ROGERS	VICE PRESIDENT, DIRECTOR	2858239	YES		05/31/2018
STUART D HOLLANDER	EXE VICE PRES, DIRECTOR	3393774	YES		05/31/2018
NATHAN GREER	SECRETARY, DIRECTOR	451-77-2609	YES		05/31/2018
STEPHEN KNAPP	CFO, TREASURER, DIRECTOR	285-74-1897	YES		05/31/2018
ADAM KARKOWSKY	DIRECTOR	115-60-1112		YES	05/31/2018
BARRY ZYSKIND	DIRECTOR	210-68-4441		YES	05/31/2018
HARRY SCHLACHTER	DIRECTOR	074-50-6936		YES	05/31/2018
MICHAEL SAXON	DIRECTOR	297-66-4885		YES	05/31/2018
STEPHEN UNGAR	DIRECTOR	106-60-3542		YES	05/31/2018

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:	CATHY KIMMEY
Title:	LICENSING SPECIALIST
Phone Number:	972-788-6811
Email Address:	PRODUCER.LICENSING@AMTRUSTGROUP.COM