Notification of Changes for Business Entity
General Information
Business Entity Name:	DUBRASKI & ASSOCIATES INSURANCE SERVICES LLC
Incorporation / Formation Date:
FEIN:	20-1994280
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	CT
County:	LITCHFIELD
Business Address
Address 1:	14 OLD BARN RD UNIT2
Address 2:
City:	KENT
State:	CT
Zip:	06757
Phone:	212-297-1487
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	420 LEXINGTON AVE RM 2700
Address 2:
City:	NEW YORK
State:	NY
Zip:	10170
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
JOHN MINA	EMPLOYEE	4469691	YES		09-12-2017
THERESA GREGG	EMPLOYEE	1822203	YES		09-12-2017
LAUREN HOOPES	EMPLOYEE	16299644	YES		09-12-2017
DAVID KALB	EMPLOYEE	546809	YES		09-12-2017
OLLIE LANDSMAN	EMPLOYEE	4622886	YES		09-12-2017

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:	KARI SMITH
Title:	LICENSING ADMIN.
Phone Number:	812-886-0191
Email Address:	KNSMITH@SUPPORTIVEIS.COM