Notification of Changes for Business Entity
General Information
Business Entity Name:	USI INSURANCE SERVICES LLC
Incorporation / Formation Date:
FEIN:	133771734
Ohio License Number:
NPN:	5306057
DBA / Trade Name:
State of Domicile:	PA
County:	PHILADELPHI
Business Address
Address 1:	ONE INTERNATIONAL PLAZA
Address 2:	SUITE 400
City:	PHILADELPHIA
State:	PA
Zip:	19113
Phone:	2064416300
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	601 UNION ST.
Address 2:	SUITE 1000
City:	SEATTLE
State:	WA
Zip:	98101
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
ROBERT L. COPE	AGENT	518809	YES		2/26/2018
WILLIAM SCOTT GANTT	AGENT	643730	YES		2/26/2018
BRUCE A. BAKER	AGENT	481915	YES		2/26/2018
JEFFREY J. HAYNES	AGENT	444975	YES		2/26/2018
STEVEN E GOLDIN	AGENT	467220	YES		2/26/2018
JEFFREY SCOTT THORNBURG	AGENT	5590888	YES		2/26/2018
KATHY CARVER	AGENT	474826	YES		2/26/2018
JONATHAN WARREN HODGES	AGENT	17088829	YES		2/26/2018
CHRISTOPHER A CASBARIAN	AGENT	4707706	YES		2/26/2018
DAVID M TRUXILLO	AGENT	4597885	YES		2/26/2018
JOSE DE JESUS SOBERANES	AGENT	17769716	YES		2/26/2018
THOMAS H BALL	AGENT	1065061	YES		2/26/2018
JAMES J BRANIFF IV	AGENT	1270330	YES		2/26/2018
JOHN R BRANIFF SR	AGENT	1172903	YES		2/26/2018
REBECCA S SHUMAN	AGENT	1566148	YES		2/26/2018

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:	JOSEPH HAYMAN
Title:	COMPLIANCE INTERN
Phone Number:	2064416300
Email Address:	LICENSING@USI.COM