Notification of Changes for Business Entity
General Information
Business Entity Name:	CRUMP LIFE INSURANCE SERVICES, INC.
Incorporation / Formation Date:
FEIN:	23-2232460
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	PA
County:	DAUPHIN
Business Address
Address 1:	4135 NORTH FRONT ST
Address 2:
City:	HARRISBURG
State:	PA
Zip:	17110
Phone:	321-421-6713
Fax:
Business Web Site Address:
Business Email Address:	ZEBBIE.RICHARDS@CRUMPINS.COM
Mailing Address
Address 1:	4135 NORTH FRONT ST
Address 2:
City:	HARRISBURG
State:	PA
Zip:	17110
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
KEITH RICHARD TISON	PRODUCER	11601928	YES		1/15/2016

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?
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:	ZEBBIE RICHARDS
Title:	LICENSING MANAGER
Phone Number:	321-421-6713
Email Address:	ZEBBIE.RICHARDS@CRUMPINS.COM