Notification of Changes for Business Entity
General Information
Business Entity Name:	STONE MOUNTAIN BENEFITS LLC
Incorporation / Formation Date:
FEIN:	813786361
Ohio License Number:	1126484
NPN:	18111094
DBA / Trade Name:
State of Domicile:	NC
County:	MECKLENBURG
Business Address
Address 1:	13024 BALLANTYNE CORPORATE PLACE
Address 2:	SUITE 400
City:	CHARLOTTE
State:	NC
Zip:	28277
Phone:	8662753590
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	13024 BALLANTYNR CORPORATE PLACE
Address 2:	SUITE 400
City:	CHARLOTTE
State:	NC
Zip:	28277
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
DAVID B AINSWORTH	DIRECTOR BROKER SOLUTIONS	8781598		YES	4/30/2017

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DAVID B AINSWORTH	DIRECTOR BROKER SOLUTIONS	8781598		YES	4/30/2017

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)	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:	BRADFORD C RICH
Title:	DIRECTOR, HCM SALES
Phone Number:	8662753590
Email Address:	SCASHION@STONEMTNBENEFITS.COM