Notification of Changes for Business Entity
General Information
Business Entity Name:	PROFESSIONAL SOLUTIONS INSURANCE SERVICES INC.
Incorporation / Formation Date:
FEIN:	20-4073361
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	IA
County:	POLK
Business Address
Address 1:	14001 UNIVERSITY AVE
Address 2:
City:	CLIVE
State:	IA
Zip:	50325
Phone:	5153134644
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	14001 UNIVERSITY AVE
Address 2:
City:	CLIVE
State:	IA
Zip:	50325
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
PAT WILSBACHER	PRODUCER	14213484		YES	10072016

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)	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:	TESS MEUSBURGER
Title:	PRODUCER LICENSING SPECIALIST
Phone Number:	515-313-4644
Email Address:	TMEUSBURGER@NCMIC.COM