Notification of Changes for Business Entity
General Information
Business Entity Name:	SMB INSURANCE
Incorporation / Formation Date:	03/15/2017
FEIN:	82-0807395
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	100 E. BROAD ST.
Address 2:	15TH FLOOR
City:	COLUMBUS
State:	OH
Zip:	43215
Phone:	8885702816
Fax:
Business Web Site Address:	SMBINSURANCE.COM
Business Email Address:
Mailing Address
Address 1:	100 E. BROAD ST.
Address 2:	15TH FLOOR
City:	COLUMBUS
State:	OH
Zip:	43215
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
JACOB WILLIAMS	PRODUCER	18526796		YES	03/31/2018

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)	NO
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?	NO
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:	MICHAEL CHAPMAN
Title:	OWNER
Phone Number:	6146890270
Email Address:	MIKE@SMBINSURANCE.COM