Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCEPTIONAL RISK ADVISORS LLC
Incorporation / Formation Date:
FEIN:	203803990
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	NJ
County:	BERGEN
Business Address
Address 1:	1 INTERNATIONAL BOULEVARD
Address 2:	SUITE 750
City:	MAHWAH
State:	NJ
Zip:	07495
Phone:	2015120110
Fax:	2015120221
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1 INTERNATIONAL BOULEVARD
Address 2:	SUITE 750
City:	MAHWAH
State:	NJ
Zip:	07495
Indicate the type of change you are seeking
Address Change:	YES
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:	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:	HALEY BROWN
Title:	EXECUTIVE ASSISTANT
Phone Number:	2013355938
Email Address:	HALEY.BROWN@EXCEPTIONALRISKADVISORS.COM