Notification of Changes for Business Entity
General Information
Business Entity Name:	LIDAC EMPLOYEE BENEFIT SOLUTIONS, LLC
Incorporation / Formation Date:
FEIN:	82-3204227
Ohio License Number:	1171281
NPN:
DBA / Trade Name:
State of Domicile:	MI
County:	KENT
Business Address
Address 1:	5664 PRAIRIE CREEK DRIVE
Address 2:
City:	CALEDONIA
State:	MI
Zip:	49316
Phone:	6165411299
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	5664 PRAIRIE CREEK DRIVE
Address 2:
City:	CALEDONIA
State:	MI
Zip:	49316
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
DOMINICK CAPOLARELLO	PRODUCER	1998350	YES		04/23/2018

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:	ALYSSA PIERCE
Title:	OPERATIONS SUPERVISOR
Phone Number:	9196535214
Email Address:	ALYSSA.PIERCE@REGED.COM