Notification of Changes for Business Entity
General Information
Business Entity Name:	TZ INSURANCE
Incorporation / Formation Date:
FEIN:	271602268
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	NJ
County:	BELGEN
Business Address
Address 1:	2200 FLETCHER AVE
Address 2:	4TH FLOOR
City:	FORT LEE
State:	NJ
Zip:	07024
Phone:	304-929-3257
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	2200 FLETCHER AVE4TH FLOOR
Address 2:
City:	FORT LEE
State:	NJ
Zip:	07024
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
DAYLIN BREA	PRODUCERS	17679405	YES		05/01/2016
DEAN MEINERT	PRODUCERS	17075115	YES		05/01/2016
DEBBIE ROSSITER	PRODUCERS	10630991	YES		05/01/2016
DEBORAH CARR	PRODUCERS	5694907	YES		05/01/2016
DEBRA BOLDS	PRODUCERS	15917760	YES		05/01/2016
DEGAN PURVIS	PRODUCERS	17038528	YES		05/01/2016
DEMETRA ZIMMERMAN	PRODUCERS	17582391	YES		05/01/2016
DENIA ANDERSON	PRODUCERS	17495025	YES		05/01/2016
DERRYE RANDALL	PRODUCERS	14860484	YES		05/01/2016
DESHONTIA JONES	PRODUCERS	15977388	YES		05/01/2016
DONNA CAPUANO	PRODUCERS	17080245	YES		05/01/2016
DONNA JACKSON	PRODUCERS	17312333	YES		05/01/2016
DOUGLAS HARDING	PRODUCERS	6863023	YES		05/01/2016
EDWARD BOBBITT JR	PRODUCERS	6592455	YES		05/01/2016
EILEEN DILLON	PRODUCERS	17596559	YES		05/01/2016

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:	MICHELE LEASURE
Title:	LICENSING SPECIALIST
Phone Number:	3049293257
Email Address:	LICENSING@TZINSURANCE.COM