Notification of Changes for Business Entity
General Information
Business Entity Name:	BUSINESS OWNERS LIABILITY TEAM, LLC
Incorporation / Formation Date:
FEIN:	27-0858517
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	HARTFORD
Business Address
Address 1:	10 WATERSIDE DRIVE, STE. 202
Address 2:
City:	FARMINGTON
State:	CT
Zip:	06032
Phone:	860-777-2620
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	10 WATERSIDE DRIVE, STE. 202
Address 2:
City:	FARMINGTON
State:	CT
Zip:	06032
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
TRUDIAN MITCHELL	AGENT	17786567	YES		03/22/2017

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:	BRIAN LAWLOR
Title:	MEMBER
Phone Number:	860-777-2620
Email Address:	BLAWLOR@BOLTINSURANCE.COM