Notification of Changes for Business Entity
General Information
Business Entity Name:	INS DIALOGUE AGENCY LLC
Incorporation / Formation Date:
FEIN:	26-4812934
Ohio License Number:	958274
NPN:	13972307
DBA / Trade Name:
State of Domicile:	MI
County:	OAKLAND
Business Address
Address 1:	300 E BIG BEAVER RD, STE 400
Address 2:
City:	TROY
State:	MI
Zip:	48083
Phone:	817-355-8572
Fax:
Business Web Site Address:
Business Email Address:	BRUCE.MICCIULLA@DIALOG-DIRECT.COM
Mailing Address
Address 1:	4301 CAMBRIDGE ROAD
Address 2:
City:	FORT WORTH
State:	TX
Zip:	76155
Indicate the type of change you are seeking
Address Change:	YES
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:	BRUCE MICCIULLA
Title:	DIRECTOR CLIENT SOLUTIONS, HEALTHCARE & INSURANCE (DRLP)
Phone Number:	817-355-8572
Email Address:	CYNTHIA.BROCKMAN@DIALOG-DIRECT.COM