Notification of Changes for Business Entity
General Information
Business Entity Name:	EQUIFY RISK SERVICES, LLC
Incorporation / Formation Date:
FEIN:	611738470
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	TX
County:	TARRANT
Business Address
Address 1:	777 MAIN STREET, SUITE 3900
Address 2:
City:	FORT WORTH
State:	TX
Zip:	76102
Phone:	8174906800
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	777 MAIN STREET, SUITE 3900
Address 2:
City:	FORT WORTH
State:	TX
Zip:	76102
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
DEBRA WATSON	RDA	1147401	YES		6/15/2017

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)	NO
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?	NO
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:	KRISTY STARLING
Title:	LICENSING MANAGER
Phone Number:	2547296180
Email Address:	KSTARLING@ILSAINC.COM