DEPARTMENT OF INSURANCE

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		3/31/2025
* If a status Is Pending, Pending Replacement,Or the record displays Affidavit On File, click On them For more details.

License Renewal Information

Class	Invoice Date	Response Due / Expiration Date	Response Received Date	Payment Received Date	Renewal Complete
Administrator	01/15/2025	03/31/2025

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