Notification of Changes for Business Entity
General Information  
Business Entity Name: TIBURON 113788055INSURANCE SERVICES
Incorporation / Formation Date:  
FEIN: 113788055
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: CA
County: SAN FRANCISCO
Business Address  
Address 1: 595 MARKET ST., 10TH FLOOR
Address 2:  
City: SAN FRANCISCO
State: CA
Zip: 94105
Phone: 4155437338
Fax:  
Business Web Site Address:  
Business Email Address: SPERRY@SELECTQUOTE.COM
Mailing Address  
Address 1: 595 MARKET ST., 10TH FLOOR
Address 2:  
City: SAN FRANCISCO
State: CA
Zip: 94105
   
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
DAVID SCHMALZ PRODUCER 16351844 YES   8/30/2016
BRADLEY TYSON PRODUCER 17673152 YES   8/30/2016
JAMES BOYER PRODUCER 17007064 YES   8/30/2016
JESSICA L CASTILLO PRODUCER 17679491 YES   8/30/2016
KAREN MARIA FACKLAM PRODUCER 17067198 YES   8/30/2016
PEREZ M. JOHNSON PRODUCER 17320255 YES   8/30/2016
REGINA R. JONES PRODUCER 15878282 YES   8/30/2016
MARIA JUAREZ PRODUCER 16982231 YES   8/30/2016
BRIANNA MCDONOUGH PRODUCER 17677088 YES   8/30/2016
           
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: CHARAN JIT SINGH
Title: CEO
Phone Number: 4155437338
Email Address: SPERRY@SELECTQUOTE.COM