Notification of Changes for Business Entity
General Information
Business Entity Name:	PRIME RISK PARTNERS INSURANCE AGENCY, LLC
Incorporation / Formation Date:
FEIN:	371788160
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	GA
County:	FULTON
Business Address
Address 1:	3820 MANSELL ROAD, SUITE 100
Address 2:
City:	ALPHARETTA
State:	GA
Zip:	30022
Phone:	6783179851
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	3820 MANSELL ROAD, SUITE 100
Address 2:
City:	ALPHARETTA
State:	GA
Zip:	30022
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
PETER MICHAEL ROBLIN	PRODUCER	964680	YES		05-01-2018

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:	SCOT KEES
Title:	EXECUTIVE VICE PRESIDENT
Phone Number:	678-682-7700
Email Address:	SKEES@PRIMERISKPARTNERS.COM