Notification of Changes for Business Entity
General Information
Business Entity Name:	MERRILL LYNCH LIFE AGENCY
Incorporation / Formation Date:
FEIN:	132808480
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	WA
County:	KING
Business Address
Address 1:	1215 FOURTH AVENUE
Address 2:
City:	SEATTLE
State:	WA
Zip:	98161
Phone:	800-333-4858
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	9000 SOUTHSIDE BLVD, BLDG 200
Address 2:
City:	JACKSONVILLE
State:	FL
Zip:	32256
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
MICHAEL LOZOWSKI	AGENT	1971920	YES		12/31/2015

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)
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:	BEVERLY FITCH
Title:	REGISTRATION ANALYST
Phone Number:	904-440-1166
Email Address:	BEVERLY.FITCH@BANKOFAMERICA.COM