Notification of Changes for Business Entity
General Information
Business Entity Name:	U.S. RISK, LLC
Incorporation / Formation Date:
FEIN:	752436502
Ohio License Number:	29543
NPN:	686639
DBA / Trade Name:
State of Domicile:	OH
County:	DALLAS
Business Address
Address 1:	8401 N CENTRAL EXPY STE 1000
Address 2:
City:	DALLAS
State:	TX
Zip:	75225
Phone:	2142657090
Fax:	2147391421
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	8401 N CENTRAL EXPY STE 1000
Address 2:
City:	DALLAS
State:	TX
Zip:	75225
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
IAN PACKER	PREVIOUS OFFICER	179588407		YES	09/08/2017
GEORGE GORNEY	CHIEF INFORMATION OFFICER	379866207	YES		09/08/2017

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:	CHRISTY KRICK
Title:	LICENSING ADMINISTRATOR
Phone Number:	8124942472
Email Address:	CKRICK@SUPPORTIVEIS.COM