Notification of Changes for Business Entity
General Information
Business Entity Name:	ASSUREDPARTNERS OF OHIO DBA DAWSON INSURANCE
Incorporation / Formation Date:
FEIN:	80-00786940
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	CUYAHOGA
Business Address
Address 1:	1340 DEPOT STREET
Address 2:
City:	ROCKY RIVER
State:	OH
Zip:	44116
Phone:	440-333-9000
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1430 DEPOT STREET
Address 2:
City:	ROCKY RIVER
State:	OH
Zip:	44116
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
JEANNE MOSCARILLO	AGENT	231454		YES	4-22-16
MAGGIE LOESER	AGENT	841442		YES	4-22-16
BRIAN STEELE	AGENT	1039210		YES	4-22-16
JENNIFER MIKSA	AGENT	50686		YES	4-22-16

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:	ANGELA DROOK
Title:	SECRETARY
Phone Number:	440-895-6338
Email Address:	ADROOK@DAWSONCOMPANIES.COM