Notification of Changes for Business Entity
General Information
Business Entity Name:	DELTA DEFENSE, LLC
Incorporation / Formation Date:
FEIN:	200364350
Ohio License Number:	1179820
NPN:	18671359
DBA / Trade Name:
State of Domicile:	OH
County:	OUT OF STATE
Business Address
Address 1:	1000 FREEDOM WAY
Address 2:
City:	WEST BEND
State:	WI
Zip:	53095
Phone:	414-881-2162
Fax:
Business Web Site Address:
Business Email Address:	CORRIE@USCCA.COM
Mailing Address
Address 1:	1000 FREEDOM WAY
Address 2:
City:	WEST BEND
State:	WI
Zip:	53095
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
DAWN ALBRECHT	PRODUCER	18659914	YES		02/05/2018
MATTHEW BERENDS	PRODUCER	18659940	YES		02/05/2018
TRICIA CADDOCK	PRODUCER	18660010	YES		02/05/2018
MARK EVANS	PRODUCER	18660003	YES		02/05/2018
CORRIE FEAVEL	PRODUCER	18661919	YES		02/05/2018
HARRY FINE	PRODUCER	18660008	YES		02/05/2018
KYLE FRYE	PRODUCER	18660024	YES		02/05/2018
DANIEL GARVEY	PRODUCER	18660043	YES		02/05/2018
JUSTIN GRAHAM	PRODUCER	18660059	YES		02/05/2018
KRISTINE GOSTOMSKI	PRODUCER	17186935	YES		02/05/2018
SPENCER JACOBSON	PRODUCER	18660082	YES		02/05/2018
CASSANDRA KUCHLER	PRODUCER	18660886	YES		02/05/2018
JEFFREY LANGE	PRODUCER	18660933	YES		02/05/2018
BROCK MAJKOWSKI	PRODUCER	18660941	YES		02/05/2018
MARISA MOSER	PRODUCER	18660936	YES		02/05/2018

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:	APRIL EATON
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-886-0191
Email Address:	ADEATON@SUPPORTIVEIS.COM