Notification of Changes for Business Entity
General Information
Business Entity Name:	MATIC INSURANCE SERVICES INC.
Incorporation / Formation Date:	04/22/2014
FEIN:	465512991
Ohio License Number:	1039887
NPN:	17264165
DBA / Trade Name:
State of Domicile:	CA
County:	CA
Business Address
Address 1:	15335 MORRISON STREET
Address 2:	SUITE 225
City:	SHERMAN OAKS
State:	CA
Zip:	91403
Phone:	8184655388
Fax:
Business Web Site Address:
Business Email Address:	MARCI@MATICINSURANCE.COM
Mailing Address
Address 1:	15335 MORRISON STREET
Address 2:	SUITE 225
City:	SHERMAN OAKS
State:	CA
Zip:	91403
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
ADAM PIERCE	AGENT	17655337	YES		07/31/2018

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:	MARCIE KAUFMAN
Title:	VP OF ADMIN
Phone Number:	8184655388
Email Address:	MARCI@MATIC.COM