Notification of Changes for Business Entity
General Information
Business Entity Name:	SBS INSURANCE AGENCY OF FLORIDA
Incorporation / Formation Date:
FEIN:	593025829
Ohio License Number:	30944
NPN:
DBA / Trade Name:
State of Domicile:	FL
County:	BOCA RATON
Business Address
Address 1:	595 SOUTH FEDERAL HIGHWAY
Address 2:	SUITE 500
City:	BOCA RATON
State:	FL
Zip:	33432
Phone:	800-879-8100
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	200 N PACIFIC COAST HIGHWAY
Address 2:	STE 1200
City:	EL SEGUNDO
State:	CA
Zip:	90245
Indicate the type of change you are seeking
Address Change:	YES
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

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:	JACKIE SMITH
Title:	LICENSE SPECIALIST
Phone Number:	800-879-8100
Email Address:	ALEXIS.WRIGHT@CETERA.COM