Notification of Changes for Business Entity
General Information
Business Entity Name:	BLOOM INSURANCE AGENCY LLC
Incorporation / Formation Date:
FEIN:	260640936
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	IN
County:	IN
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
ANDREA WILSON	LICENSED PRODUCER	11176772		YES	7/10/2017

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:	BUSINESS STRATEGIST
Phone Number:	8126505807
Email Address:	LICENSING@BLOOMINSURANCEAGENCY.COM