Notification of Changes for Business Entity
General Information
Business Entity Name:	GUY HURLEY LLC
Incorporation / Formation Date:
FEIN:	383605553
Ohio License Number:	28395
NPN:	5327701
DBA / Trade Name:
State of Domicile:	OH
County:	OAKLAND
Business Address
Address 1:	1080 KIRTS BLVD STE 500
Address 2:
City:	TROY
State:	MI
Zip:	48084
Phone:	8185191414
Fax:	2485191401
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1080 KIRTS BLVD STE 500
Address 2:
City:	TROY
State:	MI
Zip:	48084
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
JAY CUMMINGS	VICE PRESIDNET	983003		YES	06/15/2017

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:	CHRISTY KRICK
Title:	LICENSING ADMINISTRATOR
Phone Number:	8124942472
Email Address:	CKRICK@SUPPORTIVEIS.COM