Notification of Changes for Business Entity
General Information
Business Entity Name:	ROSS DIVERSIFIED INSURANCE SERVICES INC
Incorporation / Formation Date:	03/08/1988
FEIN:	330295556
Ohio License Number:	23693
NPN:	690000
DBA / Trade Name:
State of Domicile:	CA
County:	ORANGE
Business Address
Address 1:	12200 INDUSTRY STREET
Address 2:
City:	GARDEN GROVE
State:	CA
Zip:	92841
Phone:	714-379-0163
Fax:	714-379-0173
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	12200 INDUSTRY STREET
Address 2:
City:	GARDEN GROVE
State:	CA
Zip:	92841
Indicate the type of change you are seeking
Address Change:	YES
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

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:	SHELLEY HAYASHI
Title:	ACCOUNTING MANAGER
Phone Number:	714-379-0163
Email Address:	SHAYASH@ROSS2.COM