Notification of Changes for Business Entity
General Information
Business Entity Name:	HERITAGE INSURANCE ADVISORS, LLC
Incorporation / Formation Date:
FEIN:	821631609
Ohio License Number:	1149318
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	5491 SCIOTO DARBY RD.
Address 2:	SUITE 4
City:	HILLIARD
State:	OH
Zip:	43026
Phone:	6143193501
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	5491 SCIOTO DARBY RD.
Address 2:	SUITE 4
City:	HILLIARD
State:	OH
Zip:	43026
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
BRYAN SCOTT BLAU	PRODUCER	18630886	YES		12/19/2017

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:	CARL BARA
Title:	MEMBER
Phone Number:	5204907798
Email Address:	CBARA@HIA-OH.COM