Notification of Changes for Business Entity
General Information
Business Entity Name:	HBW WARRANTY ADMINISTRATION, LLC
Incorporation / Formation Date:
FEIN:	20-1610086
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	CO
County:	DENVER
Business Address
Address 1:	10375 E HARVARD AVE
Address 2:
City:	DENVER
State:	CO
Zip:	80231
Phone:	720-747-6007
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	10375 E HARVARD AVE
Address 2:
City:	DENVER
State:	CO
Zip:	80231
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
DAVID R. JOHNSON	PRODUCER - DRA (VP)	5829968	YES		4/21/2017
ALISON M. SHORT	PRODUCER - DRA (PRESIDENT)	1252219		YES	4/21/2017

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)	NO
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?	NO
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:	MICHAEL C. FLETCHER
Title:	VP, SECRETARY AND GENERAL COUNSEL
Phone Number:	720-747-6007
Email Address:	LEGAL@2-10.COM