Notification of Changes for Business Entity
General Information
Business Entity Name:	123 GROUP, LLC
Incorporation / Formation Date:
FEIN:	45-4519438
Ohio License Number:	955945
NPN:	16574016
DBA / Trade Name:	ASSOCIATED INSURANCE AGENCIES OF NEWARK
State of Domicile:	OH
County:	LICKING
Business Address
Address 1:	1335 GRANVILLE ROAD
Address 2:
City:	NEWARK
State:	OH
Zip:	43055
Phone:	6148822335
Fax:
Business Web Site Address:
Business Email Address:	MOTTO@ASSOCIATED-INS.COM
Mailing Address
Address 1:	63 COMMERCE PARK DR
Address 2:
City:	WESTERVILLE
State:	OH
Zip:	43082
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	YES	New DBA/Trade Name:	ASSOCIATED INSURANCE AGENCIES
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
MARK E OTTO

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
MARK E OTTO

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:	MARK OTTO
Title:	PARTNER
Phone Number:	6148822335
Email Address:	MOTTO@ASSOCIATED-INS.COM