Notification of Changes for Business Entity
General Information
Business Entity Name:	CRUMP LIFE INSURANCE SERVICES INC
Incorporation / Formation Date:
FEIN:	23-2232460
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	PA
County:	DAUPHIN
Business Address
Address 1:	4135 NORT FRONT STREET
Address 2:
City:	HARRISBURG
State:	PA
Zip:	17110
Phone:	321-421-6713
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P O BOX 2453
Address 2:
City:	HARRISBURG
State:	PA
Zip:	17105
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
LELIS MOTT	AGENT	18492210	YES		09-21-2017

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:	DENISE HARRISON
Title:	AUTHORIZED SUBMITTER
Phone Number:	252-246-4261
Email Address:	INSLICENSING@BBANDT.COM