Notification of Changes for Business Entity
General Information
Business Entity Name:	CAS INSURANCE AGENCY, LLC
Incorporation / Formation Date:
FEIN:	261796946
Ohio License Number:	37674
NPN:	10360291
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	19020 33RD AVE WEST SUITE 400
Address 2:
City:	LYNNWOOD
State:	WA
Zip:	98036
Phone:	2148022955
Fax:
Business Web Site Address:
Business Email Address:	RDANIELS@GREYSTAR.COM
Mailing Address
Address 1:	19020 33RD AVE WEST SUITE 400
Address 2:
City:	LYNNWOOD
State:	WA
Zip:	98036
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:	DAVE LUNDY
Title:	AUTHORIZED SUBMITTER
Phone Number:	3052532244
Email Address:	DAVE.LUNDY@ASSURANT.COM