Notification of Changes for Business Entity
General Information  
Business Entity Name: COZY INSURANCE SERVICES, LLC
Incorporation / Formation Date: 03/07/2017
FEIN: 38-4028970
Ohio License Number: 1149277
NPN: 18385332
DBA / Trade Name:  
State of Domicile: OR
County: MULTNOMAH
Business Address  
Address 1: 3514 N. VANCOUVER AVE STE 400
Address 2:  
City: PORTLAND
State: OR
Zip: 97227
Phone: 503-462-4417
Fax:  
Business Web Site Address:  
Business Email Address:  
Mailing Address  
Address 1: 3514 N. VANCOUVER AVE STE 400
Address 2:  
City: PORTLAND
State: OR
Zip: 97227
   
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
RAPHAELLA K-HERNANDEZ VICE PRESIDENT AND DRP 9081018   YES 8/21/2017
JOSEPH C. MARCINO VICE PRESIDENT AND DRP 8940323 YES   8/21/2017
           
Members, Owners, Partners, Officers and Directors
Name Title Identifying # Add Delete Eff. Date
RAPHAELLA K-HERNANDEZ VICE PRESIDENT AND DRP 9081018   YES 8/21/2017
JOSEPH C. MARCINO VICE PRESIDENT AND DRP 8940323 YES   8/21/2017
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) YES
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? YES
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement THE ENTITY'S SOLE MEMBER (OWNER) AND MANAGER, COZY SERVICES LTD., PROVIDES A VARIETY OF WEB-BASED SERVICES TO RESIDENTIAL LANDLORDS, TENANTS, AND PROSPECTIVE TENANTS AT THE COZY.CO WEBSITE. NOTE, HOWEVER, THAT THE ENTITY IS NOT AN AGENT FOR TITLE INSURANCE.
Submitted By  
Submitted By: OMID ASHTARI
Title: VICE PRESIDENT
Phone Number: 503-462-4417
Email Address: INSURANCE@COZY.CO