Notification of Changes for Business Entity
General Information
Business Entity Name:	BROOKER INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	34-1499663
Ohio License Number:	642238
NPN:	7936962
DBA / Trade Name:
State of Domicile:	OH
County:	CUYAHOGA
Business Address
Address 1:	10749 PEARL ROAD
Address 2:
City:	STRONGSVILLE
State:	OH
Zip:	44136
Phone:	440-238-5454
Fax:	440-238-0262
Business Web Site Address:
Business Email Address:	MKOENIG@BROOKER-INS.COM
Mailing Address
Address 1:	10749 PEARL ROAD
Address 2:
City:	STRONGSVILLE
State:	OH
Zip:	44136
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	CONSULTATIVE INSURANCE GROUP
New DBA/Trade Name:	NO	New DBA/Trade Name:	BROOKER INSURANCE GROUP
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
MARY JO KOENIG	ACCOUNT MANAGER		YES

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:	MARY JO KOENIG
Title:	ACCOUNT MANAGER
Phone Number:	440-238-5454
Email Address:	MKOENIG@BROKER-INS.COM