Notification of Changes for Business Entity
General Information
Business Entity Name:	RSC INSURANCE BROKERAGE INC
Incorporation / Formation Date:
FEIN:	16-1689464
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	SUFFOLK
Business Address
Address 1:	160 FEDERAL STREET
Address 2:	4TH FLOOR
City:	BOSTON
State:	MA
Zip:	02110
Phone:	212-297-1487
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	160 FEDERAL STREET
Address 2:
City:	BOSTON
State:	MA
Zip:	02110
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
CHRISTOPHER HAAS	EMPLOYEE	14277962	YES		12-12-2018

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:	KARI SMITH
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-886-0191
Email Address:	KNSMITH@SUPPORTIVEIS.COM