Notification of Changes for Business Entity
General Information
Business Entity Name:	BLOOM INSURANCE AGENCY, LLC
Incorporation / Formation Date:	07172007
FEIN:	26-0640936
Ohio License Number:	36939
NPN:	9567860
DBA / Trade Name:
State of Domicile:	IN
County:	MONROE
Business Address
Address 1:	1801 S LIBERTY DR STE 200
Address 2:
City:	BLOOMINGTON
State:	IN
Zip:	47403
Phone:	8126505807
Fax:
Business Web Site Address:
Business Email Address:	LICENSING@BLOOMINSURANCEAGENCY.COM
Mailing Address
Address 1:	1801 S LIBERTY DR STE 200
Address 2:
City:	BLOOMINGTON
State:	IN
Zip:	47403
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
KEEVEN, BRYAN	AGENT	881059	YES		10/15/2017
HAMILTON, LINDA	AGENT	17726146	YES		10/15/2017
HANSCOM, AMY	AGENT	16715320	YES		10/15/2017
HARMON, MICHELLE	AGENT	18566696	YES		11/01/2017
HERNANDEZ, VENUS	AGENT	17744266	YES		10/15/2017
HOLLER, JAMIE	AGENT	17341434	YES		10/15/2017
HUELSMAN, EUGENE	AGENT	11794459	YES		10/15/2017
KARP, ADAM	AGENT	18510596	YES		10/15/2017
KOONS, LINDSAY	AGENT	18545213	YES		10/15/2017
LAWSON, HANNAH	AGENT	18543476	YES		10/15/2017
LINVILLE, JUSTIN	AGENT	18509289	YES		10/15/2017
MCCORMICK, EILEEN	AGENT	18566704	YES		11/01/2017
MCKENNA, EDWARD	AGENT	18007176	YES		11/01/2017
MIGUEL, RYAN	AGENT	7408742	YES		11/01/2017
MITCHELL, JODEE	AGENT	17330470	YES		11/01/2017

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:	CATHERINE PEARCE
Title:	MANAGER
Phone Number:	812-650-5807
Email Address:	LICENSING@BLOOMINSURANCEAGENCY.COM