Notification of Changes for Business Entity
General Information
Business Entity Name:	SMB INSURANCE LLC
Incorporation / Formation Date:	03/15/2017
FEIN:	82-0807395
Ohio License Number:	1143048
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	DELAWARE
Business Address
Address 1:	297 BEECH TRAIL CT.
Address 2:
City:	POWELL
State:	OH
Zip:	43065
Phone:	6145166948
Fax:
Business Web Site Address:	SMBINSURANCE.COM
Business Email Address:	HI@SMBINSURANCE.COM
Mailing Address
Address 1:	41 S. HIGH ST.; SUITE 240
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43215
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
JOSHUA JORZ	PRODUCER		YES		08/01/2017
MEGAN SACKS	PRODUCER		YES		09/01/2017
JACOB WILLIAMS	PRODUCER		YES		10/01/2017

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)	NO
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?	NO
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:	MICHAEL CHAPMAN
Title:	FOUNDER AND MANAGING PARTNER
Phone Number:	6146890270
Email Address:	MIKE@SMBINSURANCE.COM