Notification of Changes for Business Entity
General Information
Business Entity Name:	CASSEL INSURANCE LLC
Incorporation / Formation Date:
FEIN:	47-2530010
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	MONTGOMERY
Business Address
Address 1:	465 ARLINGTON ROAD
Address 2:	P.O. BOX 370
City:	BROOKVILLE
State:	OH
Zip:	45309
Phone:	937-833-2107
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	465 ARLINGTON ROAD
Address 2:	P.O. BOX 370
City:	BROOKVILLE
State:	OH
Zip:	45309
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
SAUNDRA BROOKS	AGENT/CSR	17869455		YES	03/17/2016
SAUNDRA BRUCHS	AGENT/CSR	17869455	YES		03/17/2016
JACK COBLENTZ	AGENT	515965	YES		03/17/2016
CAROLE COBLENTZ	AGENT	2386163	YES		03/17/2016

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)	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:	DENNIS L. CASSEL
Title:	PRINCIPAL
Phone Number:	937-833-2107
Email Address:	TINA@CASSELINS.COM.