Notification of Changes for Business Entity
General Information
Business Entity Name:	TENNANT RISK INSURANCE AGENCY LLC
Incorporation / Formation Date:
FEIN:	542084857
Ohio License Number:	36003
NPN:	7941165
DBA / Trade Name:
State of Domicile:	OH
County:	HARTFORD
Business Address
Address 1:	124 LASALLE ROAD
Address 2:
City:	WEST HARTFORD
State:	CT
Zip:	06107
Phone:	8605191301
Fax:	8602165845
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	124 LASALLE ROAD
Address 2:
City:	WEST HARTFORD
State:	CT
Zip:	06107
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
LISA HAASER	PRODUCER	1114502	YES		08/10/2016

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:	CHRISTY KRICK
Title:	LICENSING ADMINISTRATOR
Phone Number:	8124942472
Email Address:	CKRICK@SUPPORTIVEIS.COM