Notification of Changes for Business Entity
General Information
Business Entity Name:	BAZEMORE INSURANCE GROUP
Incorporation / Formation Date:
FEIN:	81-2439241
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	5368 CENTRAL COLLEGE RD
Address 2:	SUITE 1
City:	WESTERVILLE
State:	OH
Zip:	43081
Phone:	614-559-8585
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	5368 CENTRAL COLLEGE RD
Address 2:	SUITE 1
City:	WESTERVILLE
State:	OH
Zip:	43081
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
ANGELO BANGO	PRODUCER	18604107	YES		03/10/2018

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:	CHRISTOPHER JORDAN BAZEMORE
Title:	OWNER
Phone Number:	6145598585
Email Address:	JORDAN@BAZEMOREINSURANCE.COM