Notification of Changes for Business Entity
General Information
Business Entity Name:	J&W RISK SERVICES
Incorporation / Formation Date:
FEIN:	931279767
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OR
County:	KLAMATH
Business Address
Address 1:	401 HARBOR ISLES BLVD
Address 2:
City:	KLAMATH FALLS
State:	OR
Zip:	97601
Phone:	541-885-7420
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 1657
Address 2:
City:	KLAMATH FALS
State:	OR
Zip:	97601
Indicate the type of change you are seeking
Address Change:	NO
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
KELLY BEEGLE	RDA	10278416	YES		06/03/2016
ELWOOD SINE	RDA	10358270		YES	06/03/2016

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:	APRIL EATON
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-886-0191
Email Address:	ADEATON@SUPPORTIVEIS.COM