Notification of Changes for Business Entity
General Information
Business Entity Name:	BUILDIUM AGENCY LLC
Incorporation / Formation Date:
FEIN:	32-0463931
Ohio License Number:	1077683
NPN:	17648575
DBA / Trade Name:
State of Domicile:	FL
County:	OUT OF STATE
Business Address
Address 1:	11222 QUAIL ROOST DRIVE
Address 2:
City:	MIAMI
State:	FL
Zip:	33157
Phone:	6172755059
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	11222 QUAIL ROOST DRIVE
Address 2:
City:	MIAMI
State:	FL
Zip:	33157
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
MARISA MEADE	RDA	10311667	YES		04/26/2018
CHARLETTE TRIMBLE	RDA	18250941		YES	04/26/2018

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:	APRIL EATON
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-886-0191
Email Address:	ADEATON@SUPPORTIVEIS.COM