Notification of Changes for Business Entity
General Information
Business Entity Name:	BROKERS CHOICE OF AMERICA, INC
Incorporation / Formation Date:
FEIN:	84-1157290
Ohio License Number:	24067
NPN:
DBA / Trade Name:
State of Domicile:	CO
County:	CO
Business Address
Address 1:	10700 E. GEDDES AVE SUITE 125
Address 2:
City:	ENGLEWOOD
State:	CO
Zip:	80112
Phone:	3037531417
Fax:
Business Web Site Address:
Business Email Address:	TCLARK@BROKERSCHOICE.COM
Mailing Address
Address 1:	10700 E. GEDDES AVE SUITE 125
Address 2:
City:	ENGLEWOOD
State:	CO
Zip:	80112
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
TYRONE M CLARK

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:	TYRONE CLARK
Title:	PRESIDENT
Phone Number:	303-753-1417
Email Address:	TCLARK@BROKERSCHOICE.COM