Notification of Changes for Business Entity
General Information
Business Entity Name:	ASSURED FINANCIAL GROUP LLC
Incorporation / Formation Date:
FEIN:	820943307
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	WOOD
Business Address
Address 1:	4106 MOSER LANE
Address 2:
City:	PERRYSBURG
State:	OH
Zip:	43551
Phone:	4198725020
Fax:
Business Web Site Address:
Business Email Address:	JBECHTEL@BEX.NET
Mailing Address
Address 1:	4106 MOSER LANE
Address 2:
City:	PERRYSBURG
State:	OH
Zip:	43551
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
JANE A BECHTEL

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:	JANE A BECHTEL
Title:	OWNER
Phone Number:	4198725020
Email Address:	JBECHTEL@BEX.NET