Notification of Changes for Business Entity
General Information
Business Entity Name:	ACRISURE, LLC
Incorporation / Formation Date:
FEIN:	26-3554645
Ohio License Number:	39003
NPN:
DBA / Trade Name:
State of Domicile:	MI
County:	INGHAM
Business Address
Address 1:	5664 PRAIRIE CREEK DRIVE
Address 2:
City:	CALEDONIA
State:	MI
Zip:	49316
Phone:	8007480351
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 1788
Address 2:
City:	GRAND RAPIDS
State:	MI
Zip:	49501
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:	BGS ASSOCIATES
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)
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:	ML SANDERS
Title:	CAO
Phone Number:	8007480351
Email Address:	TPARTIN@ACRISURE.COM