Notification of Changes for Business Entity
General Information
Business Entity Name:	HUBBELL SENIOR BENEFITS LLC
Incorporation / Formation Date:
FEIN:	81-2419794
Ohio License Number:	1105849
NPN:	17939269
DBA / Trade Name:
State of Domicile:	OH
County:	MONTGOMERY
Business Address
Address 1:	2431 VIENNA PARKWAY
Address 2:
City:	DAYTON
State:	OH
Zip:	45459-1400
Phone:	937-367-6262
Fax:
Business Web Site Address:	HTTP://WWW.HUBBELLSENIORBENEFITS.COM
Business Email Address:	LARRY@HUBBELLSENIORBENEFITS.COM
Mailing Address
Address 1:	PO BOX 750391
Address 2:
City:	DAYTON
State:	OH
Zip:	45475-0391
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	LAWRENCE K HUBBELL
Title:	MANAGER
Phone Number:	937-367-6262
Email Address:	LARRY@HUBBELLSENIORBENEFITS.COM