Notification of Changes for Business Entity
General Information
Business Entity Name:	POMS & ASSOC INSURANCE BROKERS LLC
Incorporation / Formation Date:	02/19/1991
FEIN:	954314381
Ohio License Number:
NPN:	1680824
DBA / Trade Name:
State of Domicile:	CA
County:	LOS ANGELES
Business Address
Address 1:	5700 CANOGA AVE
Address 2:	SUITE 400
City:	WOODLAND HILLS
State:	CA
Zip:	91367
Phone:	8184499300
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	5700 CANOGA AVE
Address 2:	SUITE 400
City:	WOODLAND HILLS
State:	CA
Zip:	91367
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
SHERRY SKARDA	RESPONSIBLE PRODUCER	633716		YES	03/22/2017
DAVID POMS	RESPONSIBLE PRODUCER	615822	YES		03/22/2017

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:	CSC
Title:	AUTHORIZED SUBMITTER
Phone Number:	8009279800
Email Address:	BLINSURANCE@CSCGLOBAL.COM