Notification of Changes for Business Entity
General Information
Business Entity Name:	SAFEHOLD SPECIAL RISK INC
Incorporation / Formation Date:	01/29/2007
FEIN:	208356926
Ohio License Number:	36296
NPN:	9142974
DBA / Trade Name:
State of Domicile:	IL
County:	COOK
Business Address
Address 1:	10 S WACKER DRIVE
Address 2:
City:	CHICAGO
State:	IL
Zip:	60606
Phone:	312-920-9177
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	100 GLEN EAGLES COURT
Address 2:	1ST FLOOR
City:	CARROLLTON
State:	GA
Zip:	30117
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:	JODIANN RAINIER
Title:	LICENSING COORDINATOR
Phone Number:	856-533-5715
Email Address:	JODIANN.RAINIER@USI.COM