Notification of Changes for Business Entity
General Information
Business Entity Name:	INSUREONE INDEPENDENT INSURANCE AGENCY, LLC
Incorporation / Formation Date:
FEIN:	364485332
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	IL
County:	DUPAGE
Business Address
Address 1:	150 HARVESTER DR STE 300
Address 2:
City:	BURR RIDGE
State:	IL
Zip:	60527
Phone:	7142522645
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	6500 INTERNATIONAL PARKWAY STE 1500
Address 2:
City:	PLANO
State:	TX
Zip:	75093
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
JOSEPH PATTEN	ASSISTANT VICE PRESIDENT	801163		YES	9/30/2015

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:	ML SANDERS
Title:	REGIONAL MANAGER
Phone Number:	2196807675
Email Address:	M.L.SANDERS@INSUREONE.COM