Notification of Changes for Business Entity
General Information
Business Entity Name:	ACRISURE LLC
Incorporation / Formation Date:
FEIN:	26-3554645
Ohio License Number:	39003
NPN:	12259059
DBA / Trade Name:
State of Domicile:	MI
County:	KENT
Business Address
Address 1:	5664 PRAIRIE CREEK DR SE
Address 2:
City:	CALEDONIA
State:	MI
Zip:	49316
Phone:	8007480351
Fax:
Business Web Site Address:	ACRISURE. LLC
Business Email Address:	INSURANCELICENSING@ACRISURE.COM
Mailing Address
Address 1:	5664 PRAIRIE CREEK DR SE
Address 2:
City:	CALEDONIA
State:	MI
Zip:	49316
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
TERRY CARSON	PRODUCER	518456	YES		10/02/2018

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:	PATRICIA COOPER
Title:	LICENSING ASSISTANT
Phone Number:	8007480351
Email Address:	INSURANCELICENSING@ACRISURE.COM