Notification of Changes for Business Entity
General Information
Business Entity Name:	KHADIWALA INSURANCE SERVICES DO, LLC
Incorporation / Formation Date:
FEIN:	81-3698407
Ohio License Number:	1124922
NPN:	18092629
DBA / Trade Name:
State of Domicile:	CO
County:	DOUGLAS
Business Address
Address 1:	304 INVERNESS WAY S #165
Address 2:
City:	ENGLEWOOD
State:	CO
Zip:	80112
Phone:	303-390-5769
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	304 INVERNESS WAY S #165
Address 2:
City:	ENGLEWOOD
State:	CO
Zip:	80112
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	KHADIWALA DISTRICT OFFICE, 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)
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:	SHAWN JOHNSON
Title:	DIRECTOR OF OPERATIONS
Phone Number:	303-784-3523
Email Address:	SHAWN.JOHNSON@NM.COM