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
MOORING, VAGAS	AGENT	18545118	YES		10/15/2017
ODYA, ROBERT	AGENT	17760190	YES		10/15/2017
OJO, OLUWATOSIN	AGENT	18545234	YES		10/15/2017
PALACIOS, ANTONIO CHRIS	AGENT	12001058	YES		10/15/2017
RADER, SHERYL	AGENT	17361709	YES		10/15/2017
RIZZO, ALBERT	AGENT	18457064	YES		10/15/2017
ROGERS, JANET	AGENT	17768069	YES		10/15/2017
SEMPERT, ELAINE	AGENT	18510596	YES		10/30/2017
SHELTON, LISA	AGENT	15113385	YES		10/15/2017
SINGER, ASHLEY	AGENT	14955857	YES		10/15/2017
SINN, PENNY	AGENT	18487499	YES		10/15/2017
SNYDER, JOYCE	AGENT	18579491	YES		11/01/2017
STEPHENS, ANN	AGENT	17430928	YES		10/15/2017
SZONYI, DAVID	AGENT	17341438	YES		10/15/2017
TURLEY, HAILEY	AGENT	18024319	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