Notification of Changes for Business Entity
General Information
Business Entity Name:	BUSINESS OWNERS LIABILITY TEAM LLC
Incorporation / Formation Date:
FEIN:	270858517
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	HARTFORD
Business Address
Address 1:	10 WATERSIDE DRIVE, STE. 202
Address 2:
City:	FARMINGTON
State:	CT
Zip:	06032
Phone:	8607772621
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	10 WATERSIDE DRIVE, STE. 202
Address 2:
City:	FARMINGTON
State:	CT
Zip:	06032
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
JAN TRZCINSKI	AGENT	17037485	YES		04/06/2017
PETER PRIMEAU	AGENT	17963324	YES		04/06/2017
JESSICA GOMES	AGENT	3479585	YES		04/06/2017

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:	BRIAN J. LAWLOR
Title:	MEMBER
Phone Number:	860-777-2621
Email Address:	BLAWLOR@BOLTINSURANCE.COM