Notification of Changes for Business Entity
General Information
Business Entity Name:	CITY SECURITIES INSURANCE, LLC
Incorporation / Formation Date:
FEIN:	45-2303628
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	IN
County:	MARION
Business Address
Address 1:	30 S. MERIDIAN ST STE 600
Address 2:
City:	INDIANAPOLIS
State:	IN
Zip:	46204
Phone:	317-844-0273
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	8900 KEYSTONE CROSSING STE 300
Address 2:
City:	INDIANAPOLIS
State:	IN
Zip:	46204
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
DERICK WARNER	AGENT	16849445	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)
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:	KARI SMITH
Title:	LICENSING ADMIN.
Phone Number:	812-886-0191
Email Address:	KNSMITH@SUPPORTIVEIS.COM