DEPARTMENT OF INSURANCE

Affiliations

Name	Self Insured Services Company, LLC	DOIID	397375	NAIC NPN	7220493

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Active	Non Resident	Administrator	Not Applicable	4/19/2010		3/31/2027
* If a status Is Pending, Pending Replacement,Or the record displays Affidavit On File, click On them For more details.

Designated Individuals

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Butler, John Ellis	385167	Administrator - Not Applicable	4/28/1987	5/31/2005
Active	Ottavi, John J	558911	Administrator - Not Applicable	4/19/2010