Notification of Changes for Business Entity
General Information
Business Entity Name:	H SQUARED, LLC
Incorporation / Formation Date:	06/2001
FEIN:	870676695
Ohio License Number:	27930
NPN:	5697223
DBA / Trade Name:	DIVERSIFIED INSURANCE GROUP
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	136 E SOUTH TEMPLE, STE 2300
Address 2:
City:	SALT LAKE CITY
State:	UT
Zip:	84111
Phone:	801-325-5000
Fax:	801-532-2804
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	136 E SOUTH TEMPLE, STE 2300
Address 2:
City:	SALT LAKE CITY
State:	UT
Zip:	84111
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	DIVERSIFIED INS GROUP
New DBA/Trade Name:	YES	New DBA/Trade Name:	H SQUARED INSURANCE BROKERS LL
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	JOSEPH HENRIOD
Title:	MANAGING PARTNER
Phone Number:	801-325-5000
Email Address:	JHENRIOD@DIVERSIFIEDINSURANCE.COM