Notification of Changes for Business Entity
General Information
Business Entity Name:	COSTIN-HUBERT INSURANCE
Incorporation / Formation Date:	03/02/1998
FEIN:	352040430
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	IN
County:	MARION
Business Address
Address 1:	7202 N SHADELAND AVE
Address 2:	SUITE 222
City:	INDIANAPOLIS
State:	IN
Zip:	46250
Phone:	3175707072
Fax:	3175707078
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	7202 N SHADELAND AVE
Address 2:
City:	INDIANAPOLIS
State:	IN
Zip:	46250
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
LESLEY M HUBERT	PRESIDENT	15848788	YES		05/25/2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
LESLEY M HUBERT	PRESIDENT	15848788	YES		05/25/2018

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:	LESLEY M HUBERT
Title:	PRESIDENT
Phone Number:	3175707072
Email Address:	HUBERTINS@GMAIL.COM