Notification of Changes for Business Entity
General Information
Business Entity Name:	AMERICAN INSURANCE ADMINISTRATORS LLC
Incorporation / Formation Date:
FEIN:	311258935
Ohio License Number:
NPN:	765507
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	3070 RIVERSIDE DR.
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43221
Phone:	2064416300
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	3070 RIVERSIDE DR.
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43221
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
MIGUEL TAVERAS	AGENT	1018185	YES		2/27/2018

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:	JOSEPH HAYMAN
Title:	COMPLIANCE INTERN
Phone Number:	2064416300
Email Address:	LICENSING@USI.COM