Notification of Changes for Business Entity
General Information
Business Entity Name:	BOAT/U.S., INC.
Incorporation / Formation Date:
FEIN:	54-1259466
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	VA
County:	FAIRFAX
Business Address
Address 1:	880 S. PICKETT STREET
Address 2:
City:	ALEXANDRIA
State:	VA
Zip:	22304
Phone:	703-461-2878
Fax:	703-461-4678
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	880 S. PICKETT ST., #22381
Address 2:
City:	ALEXANDRIA
State:	VA
Zip:	22304
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
KIRK ADAM ROSSI	N/R PRODUCER	13022416		YES	10/21/2016

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:	SHARON MCRAE
Title:	LICENSING SPECIALIST
Phone Number:	703-461-2878
Email Address:	SMCRAE@BOATUS.COM