Notification of Changes for Business Entity
General Information
Business Entity Name:	US RISK INC
Incorporation / Formation Date:
FEIN:	752436502
Ohio License Number:	29546 991859
NPN:	686639
DBA / Trade Name:
State of Domicile:	TX
County:	DALLAS
Business Address
Address 1:	8401 N CENTRAL EXPY STE 100
Address 2:
City:	DALLAS
State:	TX
Zip:	75225
Phone:	2142657090
Fax:	2147391421
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	8401 N CENTRAL EXPY STE 100
Address 2:
City:	DALLAS
State:	TX
Zip:	75225
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
GEORGE HOGAN	PRODUCER	56155		YES	01042016
KEVIN MORDARSKI	PRODUCER	10509094		YES	01042016

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)	NO
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?	NO
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:	CANDY MCKINNEY
Title:	LICENSING REPRESENTATIVE
Phone Number:	8124942392
Email Address:	CWMCKINNEY@SUPPORTIVEIS.COM