Notification of Changes for Business Entity
General Information
Business Entity Name:	CWIBENEFITS, INC.
Incorporation / Formation Date:
FEIN:	570870204
Ohio License Number:	1098355
NPN:	8265478
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	3411 SILVERSIDE ROAD, TATNALL BLDG 104
Address 2:
City:	WILMINGTON
State:	DE
Zip:	19810
Phone:	800-992-8088
Fax:
Business Web Site Address:
Business Email Address:	KDAVIS@PATNAT.COM
Mailing Address
Address 1:	P.O BOX 6125
Address 2:
City:	GREENVILLE
State:	SC
Zip:	29606
Indicate the type of change you are seeking
Address Change:	YES
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
TIMOTHY ERMATINGER	PRESIDENT, DIRECTOR	371501308		YES	07/01/2017

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:	GLORIA CAMACHO
Title:	SR COMPLIANCE ANALYST
Phone Number:	9546702928
Email Address:	GCAMACHO@PATNAT.COM