Notification of Changes for Business Entity
General Information
Business Entity Name:	FASI INSURANCE SERVICES, INC.
Incorporation / Formation Date:
FEIN:	20-1192781
Ohio License Number:	31551
NPN:
DBA / Trade Name:
State of Domicile:	CA
County:	SAN DIEGO
Business Address
Address 1:	655 W. BROADWAY
Address 2:	SUITE 1200
City:	SAN DIEGO
State:	CA
Zip:	92101
Phone:	636-534-2756
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	15455 CONWAY ROAD
Address 2:
City:	CHESTERFIELD
State:	MO
Zip:	63017
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
MARY C. BROCKLAND	AGENT	1017310		YES	03/01/2016

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
MARY C. BROCKLAND	RDA	1017310		YES	03/01/2016
MARY C. BROCKLAND	OFFICER	1017310		YES	03/01/2016
MARY C. BROCKLAND	VICE PRESIDENT	1017310		YES	03/01/2016

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:	KIM SWICK
Title:	LICENSING COORDINATOR
Phone Number:	636-534-2756
Email Address:	KSWICK@FIRSTALLIED.COM