Notification of Changes for Business Entity
General Information
Business Entity Name:	MOXIE PUBLIC ADJUSTERS LLC
Incorporation / Formation Date:	03/06/2018
FEIN:	85-5049064
Ohio License Number:
NPN:	18785708
DBA / Trade Name:
State of Domicile:	OH
County:	MIAMI
Business Address
Address 1:	357 NORTH MIAMI STREET
Address 2:
City:	WEST MILTON
State:	OH
Zip:	45383
Phone:	937-301-0963
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 221
Address 2:
City:	WEST MILTON
State:	OH
Zip:	45383
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
KENNETH DELONG	PUBLIC ADJUSTER AGENT	9212665	YES		7-17-2018

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)	NO
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?	NO
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:	JAMES SAGER
Title:	OWNER
Phone Number:	9373010963
Email Address:	JIM@MOXIEPUBLICADJUSTERS.COM