Notification of Changes for Business Entity
General Information
Business Entity Name:	SUTHERLAND GLOBAL SERVICES
Incorporation / Formation Date:
FEIN:	161287080
Ohio License Number:
NPN:	8372079
DBA / Trade Name:
State of Domicile:	NY
County:	MONROE
Business Address
Address 1:	1160 PITTSFORD VICTOR ROAD
Address 2:
City:	PITTSFORD
State:	NY
Zip:	14534
Phone:	8667748570
Fax:	7574311940
Business Web Site Address:
Business Email Address:	SGSINSLIC@SUTHERLANDGLOBAL.COM
Mailing Address
Address 1:	1313 EXECUTIVE BLVD
Address 2:
City:	CHESAPEAKE
State:	VA
Zip:	23320
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
LAKE, JASMINE M	PRODUCER	18552325	YES		11/15/2017
LAKTEEN-HINTON, LUCIA A	PRODUCER	18503279	YES		11/15/2017
LAZARTE-MONTTEDORO, BARBARA FA	PRODUCER	17716418	YES		11/15/2017
LESLIE, JAMES SCOTT	PRODUCER	18404438	YES		11/15/2017
LEVY, MICHELLE	PRODUCER	18434688	YES		11/15/2017
LOCKE, KIANA	PRODUCER	18369092	YES		11/15/2017
LUCERO, PATRICK	PRODUCER	18559517	YES		11/15/2017
MANZO, MARIA	PRODUCER	18544698	YES		11/15/2017
NICELY, ASHLEY	PRODUCER	18323204	YES		11/15/2017
ODOM, ERIN KIA	PRODUCER	18499165	YES		11/15/2017
ONGSIACO, MARIE OLGA	PRODUCER	2589830	YES		11/15/2017
PAULIN, CAYLA ANN	PRODUCER	18402901	YES		11/15/2017
PETERS, MARY	PRODUCER	18561254	YES		11/15/2017
PLASCENCIA, MOISES	PRODUCER	17433186	YES		11/15/2017
PUMPHREY, LAPORCHE	PRODUCER	18399544	YES		11/15/2017

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:	CAROLYN CLARK
Title:	LICENSING SPECIALIST
Phone Number:	866-774-8570
Email Address:	CAROLYN.CLARK@SUTHERLANDGLOBAL.COM