Notification of Changes for Business Entity
General Information
Business Entity Name:	TAS INSURANCE LLC
Incorporation / Formation Date:
FEIN:	46-3955192
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	MO
County:	CASS
Business Address
Address 1:	255 NW BLUE PKWY, STE. 102
Address 2:
City:	LEES SUMMIT
State:	MO
Zip:	64063
Phone:	(816) 554-8162
Fax:	(816) 664-8324
Business Web Site Address:
Business Email Address:	SSPURGEON@ADVANTBROKERAGE.COM
Mailing Address
Address 1:	P.O. BOX 1540
Address 2:
City:	LEES SUMMIT
State:	MO
Zip:	64063
Indicate the type of change you are seeking
Address Change:	YES
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

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:	JANET LYBRAND
Title:	SR LICENSING COORDINATOR
Phone Number:	501-664-8044
Email Address:	JFLYBRAND@CENTRALLICENSINGBUREAU.COM