Notification of Changes for Business Entity
General Information
Business Entity Name:	CLUB MEMBERS INSURANCE AGENCY, LLC.
Incorporation / Formation Date:
FEIN:	472800594
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	FL
County:	SEMINOLE
Business Address
Address 1:	1000 AAA DRIVE
Address 2:
City:	HEATHROW
State:	FL
Zip:	32746
Phone:	407-444-8608
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1000 AAA DRIVE
Address 2:
City:	HEATHROW
State:	FL
Zip:	32746
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
THOMAS DIXON	MANAGER	584686	YES		10/1/2017
LORI KEEFER	MANAGER	A138015		YES	09/30/17

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:	THOMAS DIXON
Title:	MANAGER
Phone Number:	407-444-8608
Email Address:	TDIXON@NATIONAL.AAA.COM