Notification of Changes for Business Entity
General Information
Business Entity Name:	USI INSURANCE SERVICES LLC
Incorporation / Formation Date:
FEIN:	133771734
Ohio License Number:
NPN:	5306057
DBA / Trade Name:
State of Domicile:	PA
County:	PHILADELPHIA
Business Address
Address 1:	ONE INTERNATIONAL PLAZA
Address 2:	SUITE 400
City:	PHILADELPHIA
State:	PA
Zip:	19113
Phone:	2064416300
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	601 UNION SQUARE
Address 2:	SUITE 1000
City:	SEATTLE
State:	WA
Zip:	98101
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
MIGUEL TAVERAS	PRODUCER	1018185	YES		2/26/2018
JEAN SOBIERALSKI	PRODUCER	7139681	YES		2/26/2018
DIANE MATYASOVSKY	PRODUCER	7530061	YES		2/26/2018
MATTHEW LEVI OSTROW	PRODUCER	17120242	YES		2/26/2018
SHERRI L SANDS	PRODUCER	15838415	YES		2/26/2018
GREGORY A COOKE	PRODUCER	15336102	YES		2/26/2018
MICHELLE L LOGAN	PRODUCER	2057520	YES		2/26/2018
SANDRA NIESPODZIANSKI	PRODUCER	2019609	YES		2/26/2018
TRAVIS A HILL	PRODUCER	3128067	YES		2/26/2018
LISA L FACENDA	PRODUCER	3074457	YES		2/26/2018
VAN E CROSBY	PRODUCER	633929	YES		2/26/2018
CHRISTOPHER G BURNS	PRODUCER	4602998	YES		2/26/2018
GREGORY L HOOD	PRODUCER	1727881	YES		2/26/2018
ZACHARY EATON	PRODUCER	18536397	YES		2/26/2018
CINDY K MAIN	PRODUCER	2211738	YES		2/26/2018

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)	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:	JOSEPH HAYMAN
Title:	COMPLIANCE INTERN
Phone Number:	2064416300
Email Address:	LICENSING@USI.COM