Notification of Changes for Business Entity
General Information
Business Entity Name:	AMCHECK NATIONAL BROKER SERVICES CORPORATION
Incorporation / Formation Date:
FEIN:	203794829
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	MARICOPA
Business Address
Address 1:	5030 E. SUNRISE DRIVE
Address 2:
City:	PHOENIX
State:	AZ
Zip:	85044
Phone:	4807635900
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	5030 E. SUNRISE DRIVE
Address 2:
City:	PHOENIX
State:	AZ
Zip:	85044
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
BRADLEY JOHNSTON	VICE PRESIDENT	025621469		YES	2/2/2017
DEAN LUCENTE	PRESIDENT	393869650	YES		2/2/2017

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:	HARLIE BADGETT
Title:	INSURANCE & COMPLIANCE SPECIALIST
Phone Number:	2547296179
Email Address:	HBADGETT@ILSAINC.COM