Notification of Changes for Business Entity
General Information
Business Entity Name:	PIONEER SPECIAL RISK INS SERVICES, INC
Incorporation / Formation Date:
FEIN:	320171927
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	NY
County:	NEW YORK
Business Address
Address 1:	80 BROAD STREET, SUITE 1203
Address 2:
City:	NEW YORK
State:	NY
Zip:	10004
Phone:	6469239920
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	80 BROAD STREET, SUITE 1203
Address 2:
City:	NEW YORK
State:	NY
Zip:	10004
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
EDWARD FLORES	RDA	1181882		YES	2/1/16
JANET ELIZABETH BEAVER	EMPLOYEE	7431271		YES	2/1/16
JAMES STEWART	SVP	2113743	YES		2/1/16

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
EDWARD FLORES	VP	1181882		YES	2/1/16
JANET ELIZABETH BEAVER	VP	7431271		YES	2/1/16

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:	CAROL A. HILL
Title:	AUTHORIZED PERSON
Phone Number:	817.800.5694
Email Address:	CHILL@ARCLICENSING.COM