Notification of Changes for Business Entity
General Information
Business Entity Name:	ESURANCE INSURANCE SERVICES INC
Incorporation / Formation Date:
FEIN:	26-0034575
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	DOVER
Business Address
Address 1:	650 DAVIS STREET
Address 2:
City:	SAN FRANCISCO
State:	CA
Zip:	94111
Phone:	415-875-4500
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	650 DAVIS STREET
Address 2:
City:	SAN FRANCISCO
State:	CA
Zip:	94111
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
STEPHEN MILLS	AGENT	6229535		YES	07/13/2016
ROBERTO RUIZ	AGENT	17489056		YES	05/18/2016
MICHAEL LAGUE	AGENT	17596542		YES	02/10/2016
MELISSA SMITH	AGENT	17436726		YES	03/12/2015
JOSHUA LAMB	AGENT	16919491		YES	12/17/2015
DAVID KARAPETYAN	AGENT	17592881		YES	01/17/2016
CLIFTON RAMSEY	AGENT	17125107		YES	09/16/2015
BENITO BECERRA	AGENT	13311400		YES	10/08/2015

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:	REBEKAH RATTO
Title:	LICENSING ADMINISTRATOR
Phone Number:	9164353440
Email Address:	LICENSING@CENTRAL.ESURANCE.COM