Notification of Changes for Business Entity
General Information
Business Entity Name:	ASSUREDPARTNERS OF INDIANA LLC
Incorporation / Formation Date:	01/22/2013
FEIN:	90-0927571
Ohio License Number:	985297, 985172
NPN:	16880126
DBA / Trade Name:
State of Domicile:	IN
County:	MARION
Business Address
Address 1:	10401 N MERIDIAN ST STE 300
Address 2:
City:	INDIANAPOLIS
State:	IN
Zip:	46290
Phone:	3178442159
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	C/O HERBERT L. JAMISON & CO., LLC
Address 2:	20 COMMERCE DR., SUITE 200
City:	CRANFORD
State:	NJ
Zip:	07016
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:	ERIC ANDERSON
Title:	SVP
Phone Number:	9736692301
Email Address:	SLAWRENCE@JAMISONGROUP.COM