Notification of Changes for Business Entity
General Information
Business Entity Name:	EMMETT W MACCORKLE INC INSURANCE SERVICES
Incorporation / Formation Date:
FEIN:	94-2708394
Ohio License Number:	1000321
NPN:
DBA / Trade Name:
State of Domicile:	CA
County:	SAN MATEO
Business Address
Address 1:	700 AIRPORT RD STE 300
Address 2:
City:	BURLINGAME
State:	CA
Zip:	94010
Phone:	212-297-1487
Fax:	212-573-4054
Business Web Site Address:
Business Email Address:	BROSE@RISK-STRATEGIES.COM
Mailing Address
Address 1:	420 LEXINGTON AVE RM 2700
Address 2:
City:	NEW YORK
State:	NY
Zip:	10170
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:	BEVERLY LANCASTER
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-44-2478
Email Address:	BJLANCASTER@SUPPORTIVEIS.COM