Notification of Changes for Business Entity
General Information
Business Entity Name:	ORBITZ TRAVEL INSURANCE SERVICES
Incorporation / Formation Date:
FEIN:	300452979
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	2711 CENTERVILLE RD, STE 400
Address 2:
City:	WILMINGTON
State:	DE
Zip:	19808
Phone:	866-455-6116
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	500 W. MADISON ST, STE 1000
Address 2:
City:	CHICAGO
State:	IL
Zip:	60661
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
EMAN BARHOUMEH	GLOBAL TRAVEL INSURANCE MGR	1080088	YES		09/22/2016
SAMUEL FULTON	VICE PRESIDENT	760804		YES	09/22/2016
STEPHEN PRAVEN	VP, BUSINESS DEVELOPMENT	994270		YES	09/22/2016

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:	LUZ PLAZA
Title:	LICENSING SPECIALIST
Phone Number:	866-455-6116
Email Address:	LICENSING@ALLIANZASSISTANCE.COM