Notification of Changes for Business Entity
General Information
Business Entity Name:	SRA INSURANCE AGENCY, LLC
Incorporation / Formation Date:	09/18/2012
FEIN:	80-0851585
Ohio License Number:	977319
NPN:	16796280
DBA / Trade Name:
State of Domicile:	KS
County:	JOHNSON
Business Address
Address 1:	5201 JOHNSON DR. SUITE 500
Address 2:
City:	MISSION
State:	KS
Zip:	66205
Phone:	9132363032
Fax:
Business Web Site Address:
Business Email Address:	SLAWRENCE@JAMISONGROUP.COM
Mailing Address
Address 1:	20 COMMERCE DR., SUITE 200
Address 2:
City:	CRANFORD
State:	NJ
Zip:	07016
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
GARY REMLEY	PRODUCER	226784	YES		11/09/2016

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:	ERIC ANDERSON
Title:	VP
Phone Number:	9736692301
Email Address:	EANDERSON@ASSUREDPTR.COM