Notification of Changes for Business Entity
General Information
Business Entity Name:	EZ INSURANCE GROUP INC
Incorporation / Formation Date:
FEIN:	820893628
Ohio License Number:	1154416
NPN:	18463186
DBA / Trade Name:	EZ INSURANCE GROUP INC
State of Domicile:	OH
County:	NA
Business Address
Address 1:	443 GREGORY AVE APT 2A
Address 2:
City:	GLENDALE HEIGHTS
State:	IL
Zip:	60139
Phone:	8477362866
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	443 GREGORY AVE APT 2A
Address 2:
City:	GLENDALE HEIGHTS IL
State:	IL
Zip:	60139
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
REBIELINSKA	RDA	17309702		YES	07/31/2017
REBIELINSKA	PRESIDENT	17309702		YES	07/31/2017

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
BEATA REBIELINSKA

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:	BEATA REBIELINSKA
Title:	PRESIDENT / AGENT
Phone Number:	8477362866
Email Address:	BEATASPE@YAHOO.COM