Notification of Changes for Business Entity
General Information
Business Entity Name:	BRIGHTSTAR AGENCY, LLC
Incorporation / Formation Date:
FEIN:	26-4240730
Ohio License Number:	39508
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	FULTON
Business Address
Address 1:	2325 LAKEVIEW PARKWAY
Address 2:	STE 700
City:	ALPHARETTA
State:	GA
Zip:	30009
Phone:	678-389-6218
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	2325 LAKEVIEW PARKWAY
Address 2:	STE 700
City:	ALPHARETTA
State:	GA
Zip:	30009
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	ESECURITEL AGENCY, LLC
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:	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)	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:	KELLY POTTS
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-494-2395
Email Address:	KDPOTTS@SUPPORTIVEIS.COM