Notification of Changes for Business Entity
General Information
Business Entity Name:	NT INSURANCE SERVICES LLC
Incorporation / Formation Date:	11162015
FEIN:	20-4452800
Ohio License Number:	1075548
NPN:	8832538
DBA / Trade Name:
State of Domicile:	CA
County:	SAN DIEGO
Business Address
Address 1:	16935 W. BERNARDO DR. SUITE 150
Address 2:
City:	SAN DIEGO
State:	CA
Zip:	92127
Phone:	858-444-3260
Fax:	858-444-3261
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	16935 W. BERNARDO DR. SUITE 150
Address 2:
City:	SAN DIEGO
State:	CA
Zip:	92127
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
BRENDA SHIRLEY	PRODUCER	543508	YES		12/15/15

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:	LELANY LIM
Title:	CAO
Phone Number:	858-444-3260
Email Address:	INFO@VALWESTINC.COM