Notification of Changes for Business Entity
General Information  
Business Entity Name: SELECTQUOTE INSURANCE SERVICES
Incorporation / Formation Date:  
FEIN: 680027389
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: CA
County: SAN FRANCISCO
Business Address  
Address 1: 595 MARKET ST., 10TH FLOOR
Address 2:  
City: SAN FRANCISCO
State: CA
Zip: 94105
Phone: 4155437338
Fax:  
Business Web Site Address:  
Business Email Address: SPERRY@SELECTQUOTE.COM
Mailing Address  
Address 1: 595 MARKET ST., 10TH FLOOR
Address 2:  
City: SAN FRANCISCO
State: CA
Zip: 94105
   
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
BRIAN MATTHEW BARRETT PRODUCER 16271058 YES   11/14/2017
BENJAMIN ROMAN BELTRAN PRODUCER 16815731 YES   11/14/2017
LORI SUE KROUT PRODUCER 8593410 YES   11/14/2017
JUAN ANTHONY LEARY PRODUCER 17695975 YES   11/14/2017
DAVID CARL MATHISON PRODUCER 16682845 YES   11/14/2017
DONALD ELLIS MCINTYRE PRODUCER 16394282 YES   11/14/2017
MICHAEL ARTHUR WAGNER PRODUCER 18364149 YES   11/14/2017
           
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: CHARAN JIT SINGH
Title: CEO
Phone Number: 4155437338
Email Address: SPERRY@SELECTQUOTE.COM