Notification of Changes for Business Entity
General Information
Business Entity Name:	LEAVITT RECREATION & HOSPITALITY INSURANCE INC
Incorporation / Formation Date:
FEIN:	840959596
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	CO
County:	DENVER
Business Address
Address 1:	942 14TH STREET
Address 2:
City:	STURGIS
State:	SD
Zip:	57785
Phone:	6054234341
Fax:
Business Web Site Address:
Business Email Address:	JILL-DELL@LEAVITT.COM
Mailing Address
Address 1:	942 14TH STREET
Address 2:
City:	STURGIS
State:	SD
Zip:	57785
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	SHANNON WETZSTEON / LICENSING PROFESSIONALS
Title:	LICENSING SPECIALIST
Phone Number:	8885435432
Email Address:	SWETZSTEON@LICENSINGPROS.COM