Notification of Changes for Business Entity
General Information
Business Entity Name:	XERCOR INSURANCE SERVICES LLC
Incorporation / Formation Date:	04/07/2015
FEIN:	473658523
Ohio License Number:	1094913
NPN:	17687370
DBA / Trade Name:
State of Domicile:	IN
County:	MARION
Business Address
Address 1:	8435 KEYSTONE CROSSING
Address 2:	SUITE 240
City:	INDIANAPOLIS
State:	IN
Zip:	46240
Phone:	317-757-3037
Fax:
Business Web Site Address:
Business Email Address:	MAUREEN.LEE@XERCOR.COM
Mailing Address
Address 1:	8435 KEYSTONE CROSSING
Address 2:	SUITE 240
City:	INDIANAPOLIS
State:	IN
Zip:	46240
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
KELLEY HARDISTY	DIRECTOR	086-46-7051	YES		6/21/18
FOY COOLEY	DIRECTOR	087-36-8367	YES
JOANNE GEILER	DIRECTOR	563-54-3526	YES

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

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