Notification of Changes for Business Entity
General Information
Business Entity Name:	JLBJR ENTERPRISES INC
Incorporation / Formation Date:
FEIN:	26 2190659
Ohio License Number:	1015235 1021803
NPN:	10949185
DBA / Trade Name:
State of Domicile:	OH
County:	TAMPA
Business Address
Address 1:	3000 BAYPORT DRIVER SUITE 400
Address 2:
City:	TAMPA
State:	FL
Zip:	33607
Phone:	8132871721
Fax:	8132871850
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	3000 BAYPORT DRIVE SUITE 400
Address 2:
City:	TAMPA
State:	FL
Zip:	33607
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
JUDY BESNARD	PRESIDENT	109408528		YES
SHELLEY BARNES	DIRECTOR	595096324		YES

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