Notification of Changes for Business Entity
General Information
Business Entity Name:	BIZINSURE LLC
Incorporation / Formation Date:
FEIN:	454217907
Ohio License Number:
NPN:	16611798
DBA / Trade Name:
State of Domicile:	CA
County:	ALAMEDA
Business Address
Address 1:	222 BROADWAY SUITE 6
Address 2:
City:	OAKLAND
State:	CA
Zip:	94607
Phone:	415-275-2679
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	222 BROADWAY SUITE 6
Address 2:
City:	OAKLAND
State:	CA
Zip:	94607
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
TRICIA LEE	PRODUCER	16798118	YES		12/20/2016

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)
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:	BARBARA CAMPBELL
Title:	COMPLIANCE SPECIALIST
Phone Number:	254-729-8002
Email Address:	BCAMPBELL@ILSAINC.COM