Notification of Changes for Business Entity
General Information
Business Entity Name:	HAVEN LIFE INSURANCE AGENCY, LLC
Incorporation / Formation Date:	08/04/2015
FEIN:	462252944
Ohio License Number:	1045871
NPN:	16953137
DBA / Trade Name:
State of Domicile:	NY
County:	NEW YORK
Business Address
Address 1:	205 EAST 42ND STREET, 20TH FLOOR
Address 2:
City:	NEW YORK
State:	NY
Zip:	10017
Phone:	646-762-0290
Fax:	413-744-1295
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	205 EAST 42ND STREET, 20TH FLOOR
Address 2:
City:	NEW YORK
State:	NY
Zip:	10017
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	YES	New DBA/Trade Name:	VALORALIFE INSURANCE SERVICES
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

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)	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:	YARON BEN-ZVI
Title:	PRESIDENT AND MANAGER
Phone Number:	646-762-0290
Email Address:	YARON@HAVENLIFE.COM