Notification of Changes for Business Entity
General Information
Business Entity Name:	APPLIED RISK SERVICES, INC.
Incorporation / Formation Date:
FEIN:	943339969
Ohio License Number:	25996
NPN:
DBA / Trade Name:
State of Domicile:	NE
County:	DOUGLAS
Business Address
Address 1:	10805 OLD MILL ROAD
Address 2:
City:	OMAHA
State:	NE
Zip:	68154
Phone:	4028273416
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 3646
Address 2:
City:	OMAHA
State:	NE
Zip:	68103
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
CHRISTOPHER LAMANTIA	AGENT	8353963		YES	04/14/16
TODD BROWN	AGENT	17143960	YES		04/14/16

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:	AMBER LARSEN
Title:	SR. TAX ASSOCIATE
Phone Number:	4028273416
Email Address:	INSADMIN@AUW.COM