Notification of Changes for Business Entity
General Information
Business Entity Name:	DELTA DEFENSE, LLC
Incorporation / Formation Date:	09/15/2003
FEIN:	20-0364350
Ohio License Number:	1179820
NPN:	18671359
DBA / Trade Name:
State of Domicile:	WI
County:	OUT OF STATE
Business Address
Address 1:	1000 FREEDOM WAY
Address 2:
City:	WEST BEND
State:	WI
Zip:	53095
Phone:	414-881-2162
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1000 FREEDOM WAY
Address 2:
City:	WEST BEND
State:	WI
Zip:	53095
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
MICHAEL BAUER	AGENT	18736140	YES		04/13/2018
MARK CRITCHLOW	AGENT	18730861	YES		04/13/2018
DACIA DONALDSON	AGENT	18730870	YES		04/13/2018
ASHLEY JOHNSON	AGENT	18730875	YES		04/13/2018
AMANDA JOHANEK	AGENT	18730844	YES		04/13/2018
KYLE KLOETY	AGENT	18730846	YES		04/13/2018
JESSE KORTH	AGENT	18746968	YES		04/13/2018
SALINA LEHN	AGENT	18730890	YES		04/13/2018
BOBBY ORDONEZ	AGENT	18736146	YES		04/13/2018
JUSTIN PETERS	AGENT	18730881	YES		04/13/2018
PRICILLA SCHLEHLEIN	AGENT	18736278	YES		04/13/2018
RICHARD SCHMIDT	AGENT	18730806	YES		04/13/2018
ELANA SEIDLER	AGENT	18730933	YES		04/13/2018
BRAYDEN WENDT	AGENT	18736299	YES		04/13/2018

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