Notification of Changes for Business Entity
General Information
Business Entity Name:	SAFE HARBOR ZONE LLC
Incorporation / Formation Date:	01/26/2017
FEIN:	81-5193978
Ohio License Number:	1138296
NPN:	18317091
DBA / Trade Name:
State of Domicile:	OH
County:	SUMMIT
Business Address
Address 1:	6857 AMHERST DR #2305
Address 2:
City:	SAGAMORE HILLS
State:	OH
Zip:	44067
Phone:	3309980627
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	6857 AMHERST DR #2305
Address 2:
City:	SAGAMORE HILLS
State:	OH
Zip:	44067
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
MIRCEA NOVAC	PRODUCER/OWNER	17553798	YES		03/06/2017

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:	MIRCEA NOVAC
Title:	OWNER
Phone Number:	3309980627
Email Address:	HARBORZONE@GMAIL.COM