Notification of Changes for Business Entity
General Information
Business Entity Name:	BUILDIUM AGENCY LLC
Incorporation / Formation Date:
FEIN:	320463931
Ohio License Number:	100230081
NPN:
DBA / Trade Name:
State of Domicile:	FL
County:	DADE
Business Address
Address 1:	1122 QUAIL ROOST DR
Address 2:
City:	MIAMI
State:	FL
Zip:	33157
Phone:	6172755059
Fax:	88884141933
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	225 FRANKLIN STE STE 350
Address 2:
City:	BOSTON
State:	MA
Zip:	02110
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
CHARLETTE TRIMBLE	RDA	425437096	YES		01/23/2018
RAPHAELLA FERNANDEZ	RDA	265857097		YES	01/23/2018

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:	CANDY MCKINNEY
Title:	LICENSING REP
Phone Number:	8124942392
Email Address:	CWMCKINNEY@SUPPORTIVEIS.COM