Notification of Changes for Business Entity
General Information  
Business Entity Name: PETFIRST HEALTHCARE, LLC
Incorporation / Formation Date:  
FEIN: 20-1360022
Ohio License Number:
NPN: 8654037
DBA / Trade Name:  
State of Domicile: IN
County: CLARK
Business Address  
Address 1: ONE QUARTERMASTER COURT
Address 2:  
City: JEFFERSONVILLE
State: IN
Zip: 47130
Phone: 812-206-6928
Fax:  
Business Web Site Address:  
Business Email Address:  
Mailing Address  
Address 1: ONE QUARTERMASTER COURT
Address 2:  
City: JEFFERSONVILLE
State: IN
Zip: 47130
   
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
SARAH GRACE BOMMARITO PRODUCER 18208721 YES   03/16/2017
BOBBY MCBRIAN SLOAN PRODUCER 18282448 YES   03/16/2017
MEGHAN MARCIA FAHY PRODUCER 17903060   YES 03/16/2017
SAMUEL PAUL RATLIFF PRODUCER 17816980   YES 03/16/2017
           
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: CYNTHIA L. BURLESON
Title: DIRECTOR OF COMPLIANCE AND RISK MANAGEMENT
Phone Number: 812-206-6928
Email Address: CBURLESON@PETFIRSTHEALTHCARE.COM