Notification of Changes for Business Entity
General Information
Business Entity Name:	WORKSITE BENEFITS
Incorporation / Formation Date:	04/18/2012
FEIN:	46-2706522
Ohio License Number:	994622
NPN:	16985096
DBA / Trade Name:
State of Domicile:	GA
County:	FULTON
Business Address
Address 1:	4080 MCGINNIS FERRY RD. SUITE 1001
Address 2:
City:	ALPHARETTA
State:	TX
Zip:	30005
Phone:	2148712118
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	825 MARKET ST. SUITE 300
Address 2:
City:	ALLEN
State:	TX
Zip:	75013
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	WORKSITE BENEFITS INC.
New DBA/Trade Name:	NO	New DBA/Trade Name:	HOMELAND@WORK INC.
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

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:	SHERRIE OWENS
Title:	LICENSING MANAGER
Phone Number:	2148712118
Email Address:	LICENSING@HOMELANDHEALTHCARE.COM