Notification of Changes for Business Entity
General Information  
Business Entity Name: NATIONS INSURANCE SOLUTIONS LLC
Incorporation / Formation Date:  
FEIN: 202224497
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: FL
County: MIAMI-DADE
Business Address  
Address 1: 20725 NE 16 AVENUE
Address 2: SUITE A-24
City: MIAMI
State: FL
Zip: 33179
Phone: 855-325-1795
Fax:  
Business Web Site Address:  
Business Email Address: MARC@NATIONSIS.COM
Mailing Address  
Address 1: 20725 NE 16 AVENUE
Address 2: SUITE A-24
City: MIAMI
State: FL
Zip: 33179
   
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
MUSTAPHA, ADAM PRODUCER 17069064 YES   04/12/2016
SCAMARONE, HUGO O PRODUCER 17122103 YES   04/12/2016
RICHMAN, IVAN PRODUCER 16204007 YES   04/12/2016
JOHNSON, LUCKESHA ELIZABETH PRODUCER 17307276 YES   04/12/2016
ROWE, NATALIA PRODUCER 17385863 YES   04/12/2016
DIXON, RICHARD ANTHONY PRODUCER 8687423 YES   04/12/2016
PEGLER, ROBERT PRODUCER 16279699 YES   04/12/2016
BAKER, TERENA MARIE PRODUCER 8610695 YES   04/12/2016
           
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? NO
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: DANIEL GARAVUSO
Title: DIRECTOR, COMPLIANCE
Phone Number: 8133971493
Email Address: DGARAVUSO@HIIQUOTE.COM