Notification of Changes for Business Entity
General Information  
Business Entity Name: BLOOM INSURANCE AGENCY, LLC
Incorporation / Formation Date: 07172007
FEIN: 26-0640936
Ohio License Number: 36939
NPN: 9567860
DBA / Trade Name:  
State of Domicile: IN
County: MONROE
Business Address  
Address 1: 1801 S LIBERTY DR STE 200
Address 2:  
City: BLOOMINGTON
State: IN
Zip: 47403
Phone: 8126505807
Fax:  
Business Web Site Address:  
Business Email Address: LICENSING@BLOOMINSURANCEAGENCY.COM
Mailing Address  
Address 1: 1801 S LIBERTY DR STE 200
Address 2:  
City: BLOOMINGTON
State: IN
Zip: 47403
   
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
WHITFIELD, LYTORIA AGENT 12366248 YES   10/15/2017
WOLFE, JANELLE AGENT 17982326 YES   10/15/2017
GLYNN, MEGHAN AGENT 18547148 YES   10/15/2017
WAERS, SHAWN AGENT 18100267 YES   10/15/2017
DIEDERICH, ROBERT AGENT 7962545 YES   10/15/2017
MCKEAVER, AKEVA AGENT 18122787  YES   10/15/2017
BRIDGMAN, TAYLOR AGENT 10475600  YES   10/15/2017
HARPER, JAMES AGENT 15706577 YES   10/15/2017
CORIELL, CHRISTOPHER AGENT 9112569 YES   10/15/2017
           
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: CATHERINE PEARCE
Title: MANAGER
Phone Number: 812-650-5807
Email Address: LICENSING@BLOOMINSURANCEAGENCY.COM