Notification of Changes for Business Entity
General Information
Business Entity Name:	RISK SPECIALISTS COMPANIES INSURANCE AGENCY INC.
Incorporation / Formation Date:
FEIN:	222174788
Ohio License Number:	36827
NPN:	3687951
DBA / Trade Name:
State of Domicile:	MA
County:	SUFFOLK
Business Address
Address 1:	99 HIGH STREET
Address 2:
City:	BOSTON
State:	MA
Zip:	02110-2378
Phone:	9086793206
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	99 HIGH STREET
Address 2:
City:	BOSTON
State:	MA
Zip:	02110-2378
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
KEVIN SULLIVAN		7234031		YES	10/19/16

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:	BARBARA CAMPBELL
Title:	COMPLIANCE SPECIALIST
Phone Number:	254-729-8002
Email Address: