Notification of Changes for Business Entity
General Information
Business Entity Name:	USI INSURANCE SERVICES NATIONAL, INC.
Incorporation / Formation Date:
FEIN:	561882208
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	NC
County:	MECKLENBURG
Business Address
Address 1:	6100 FAIRVIEW ROAD, SUITE 1400
Address 2:
City:	CHARLOTTE
State:	NC
Zip:	28210
Phone:	980-495-0822
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	6100 FAIRVIEW ROAD, SUITE 1400
Address 2:
City:	CHARLOTTE
State:	NC
Zip:	28210
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
JOY FREDERICK	PRODUCER	7672842		YES	05/03/2018

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)	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:	SARAH THEVENIN
Title:	LICENSING COORDINATOR
Phone Number:	980-495-0822
Email Address:	SARAH.THEVENIN@USI.COM