Notification of Changes for Business Entity
General Information
Business Entity Name:	AMERILIFE, LLC
Incorporation / Formation Date:
FEIN:	27-1442976
Ohio License Number:	40735
NPN:
DBA / Trade Name:
State of Domicile:	FL
County:	PIINELLAS
Business Address
Address 1:	2650 MCCORMICK DRIVE
Address 2:
City:	CLEARWATER
State:	FL
Zip:	33759
Phone:	7272160859
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	2650 MCCORMICK DR
Address 2:
City:	CLEARWATER
State:	FL
Zip:	33759
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	AMERILIFE & HEALTH SERVICES, L
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:	TIMOTHY NORTH
Title:	MANAGER
Phone Number:	7272160859
Email Address:	TDUNCAN@AMERILIFE.COM