Notification of Changes for Business Entity
General Information
Business Entity Name:	RSI INSURANCE BROKERS, INC.
Incorporation / Formation Date:
FEIN:	33-0359094
Ohio License Number:	30187
NPN:	687212
DBA / Trade Name:
State of Domicile:	CA
County:	ORANGE
Business Address
Address 1:	4000 WESTERLY PLACE, SUITE 110
Address 2:
City:	NEWPORT BEACH
State:	CA
Zip:	92660
Phone:	714-546-6616
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	SAME ABOVE
Address 2:
City:	SAME
State:	CA
Zip:	92660
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
BERNARD THOMAS	DLRP	637748		YES	5-17-18

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:	MARYANN MARTONE
Title:	FILER
Phone Number:	8009279800
Email Address:	BLINSUR@CSCGLOBAL.COM