Notification of Changes for Business Entity
General Information
Business Entity Name:	1 & DONE AGENCY LLC
Incorporation / Formation Date:
FEIN:	463151989
Ohio License Number:	1016447
NPN:	17117813
DBA / Trade Name:
State of Domicile:	CT
County:	HARTFORD
Business Address
Address 1:	2461 MAIN ST
Address 2:	4TH FLOOR
City:	GLASTONBURY
State:	CT
Zip:	06033
Phone:	860-554-0470
Fax:
Business Web Site Address:
Business Email Address:	ANNEK@1NDONE.ORG
Mailing Address
Address 1:	2461 MAIN ST
Address 2:	4TH FLOOR
City:	GLASTONBURY
State:	CT
Zip:	06033
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:	ANNE KELLY
Title:	OWNER
Phone Number:	860-896-5934
Email Address:	ANNEK@1NDONE.ORG