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
STRAND, JONATHAN	AGENT	9628168	YES		10/15/2017
WILLIAMS, GREGORY	AGENT	17855082	YES		10/15/2017
ARGERAS, GEORGE	AGENT	2441274	YES		10/15/2017
BORKOWSKI, TIMOTHY	AGENT	17230935	YES		10/15/2017
MANN, EBONY	AGENT	17370779	YES		10/15/2017
STOLL, GARY	AGENT	9872862	YES		10/15/2017
TRACY JR, MICHAEL	AGENT	8902595	YES		10/15/2017
WHITE, JULIE	AGENT	17172939	YES		10/15/2017
ANDERSON, RANDAL	AGENT	11199802	YES		10/15/2017
BENAVENTE-ORNA, MARCELO	AGENT	17951081	YES		10/15/2017
HATFIELD, MARK	AGENT	18523388	YES		10/15/2017
KIMBROUGH, TOMEKA	AGENT	2899002	YES		10/15/2017
SMITH, SARAH	AGENT	18504468	YES		10/15/2017
THOMPSON, KIMBERLY	AGENT	18522462	YES		10/15/2017
WALDEN, CHRIS	AGENT	16674021	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