Notification of Changes for Business Entity
General Information  
Business Entity Name: SUTTHERLAND GLOBAL SERVICES
Incorporation / Formation Date:  
FEIN: 161287080
Ohio License Number:
NPN:
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:  
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
BARKER, IESHA P PRODUCER 1189554 YES   08/07/2018
BRIDGEFORD, JASMINE HONAI PRODUCER 1199447 YES   08/07/2018
LAZARUS, BIJOY PRODUCER 1199263 YES   08/07/2018
ROBERTS, ANTONIETTE PRODUCER 1199201 YES   08/07/2018
THOMAS, TEJUANA D PRODUCER 1199208 YES   08/07/2018
WILLIAMS BUSH, JENNIFER D PRODUCER 1155706 YES   08/07/2018
WORTHY, TIMOTHY VERNARD PRODUCER 1168697 YES   08/07/2018
HARRIS, LAUREN MICHELLE PRODUCER 1200592 YES   08/07/2018
JONES, TAMYRA OCTAVIA PRODUCER 1200857 YES   08/07/2018
           
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) 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: CAROLYN CLARK
Title: LICENSING SPECIALIST
Phone Number: 8667748570
Email Address: SGSINSLIC@SUTHERLANDGLOBAL.COM