Notification of Changes for Business Entity
General Information
Business Entity Name:	ASSUREDPARTNERS OF OHIO
Incorporation / Formation Date:
FEIN:	80-0786940
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	CUYAHOGA
Business Address
Address 1:	1340 DEPOT STREET
Address 2:
City:	ROCKY RIVER
State:	OH
Zip:	44116
Phone:	440-333-9000
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1340 DEPOT STREET
Address 2:
City:	ROCKY RIVER
State:	OH
Zip:	44116
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
HOLLY GRIFFITHS	AGENT	2223580		YES	8-31-16
KRISTIN GRACE STEELE	AGENT	12067460		YES	10-24-16
LORRAINE ROSE REMBOLD	AGENT	6836843		YES	10-14-16
MARY BINDREITTER	AGENT	17775399		YES	10-1-16
SERENA CHRISTINE TURCHIK	AGENT	16553081		YES	9-23-16
TODD P. GROH	AGENT	2772618		YES	10-12-16
DOUGLAS DONAUGH	AGENT	1746730	YES		4-1-16
ERIN LANCASTER	AGENT	17853042	YES		9-1-16
JONATHAN LLOYD PUTT	AGENT	18149652	YES		10-10-16
KAREN E. FUREY	AGENT	3630125	YES		9-6-16
MELANIE LYNN MOORE	AGENT	8567711	YES		10-17-16
TERESA LOUISE BENNETT	AGENT	1870394	YES		4-20-16

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:	ANGELA DROOK
Title:	ASSISTANT SECRETARY
Phone Number:	440-333-9000
Email Address:	ADROOK@DAWSONCOMPANIES.COM