Notification of Changes for Business Entity
General Information
Business Entity Name:	ELLSA GROUP ENTERPRISE AND HOLDINGS LLC
Incorporation / Formation Date:
FEIN:	465241775
Ohio License Number:	1022229
NPN:
DBA / Trade Name:	BUDZINSKI INSURANCE LLC
State of Domicile:	OH
County:	LUCAS
Business Address
Address 1:	2968 W SYLVANIA AVE.
Address 2:
City:	TOLEDO
State:	OH
Zip:	43613
Phone:	4192935020
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	2968 W SYLVANIA AVE.
Address 2:
City:	TOLEDO
State:	OH
Zip:	43613
Indicate the type of change you are seeking
Address Change:	YES
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	YES	New DBA/Trade Name:	BUDZINSKI INSURANCE LLC
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

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:	TIFFANY BUDZINSKI
Title:	PRINCIPAL AGENT
Phone Number:	4192935020
Email Address:	TIFFANY@BUDZINSKIINSURANCE.COM