Notification of Changes for Business Entity
General Information
Business Entity Name:	ALLIED PUBLIC RISK LLC
Incorporation / Formation Date:
FEIN:	47-2409703
Ohio License Number:	558105
NPN:	2705791
DBA / Trade Name:
State of Domicile:	OH
County:	PLACER
Business Address
Address 1:	3664 MINERS RAVINE DR
Address 2:
City:	ROSEVILLE
State:	CA
Zip:	95661
Phone:	9167712715
Fax:	9167730348
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	3664 MINERS RAVINE DR
Address 2:
City:	ROSEVILLE
State:	CA
Zip:	95661
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
MARY CHIU	RDA	2705791	YES		03/07/2017

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:	CHRISTY KRICK
Title:	LICENSING ADMINISTRATOR
Phone Number:	8124942472
Email Address:	CKRICK@SUPPORTIVEIS.COM