Notification of Changes for Business Entity
General Information
Business Entity Name:	BCA INSURANCE GROUP LLC
Incorporation / Formation Date:
FEIN:	263571017
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	WOOD
Business Address
Address 1:	28350 KENSINGTON LN., STE 100
Address 2:
City:	PERRYSBURG
State:	OH
Zip:	43551
Phone:	4199310742
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	28350 KENSINGTON LN., STE 100
Address 2:
City:	PERRYSBURG
State:	OH
Zip:	43551
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
KYLE GANSS	PRODUCER	17539595	YES		08/15/2016

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:	KATHERINE WILLIAMS
Title:	MANAGING MEMBER
Phone Number:	4199310742
Email Address:	KATHYW@BCA-INS.COM