Notification of Changes for Business Entity
General Information
Business Entity Name:	BLEND INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	824049233
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	CA
County:	SAN FRANCISCO
Business Address
Address 1:	415 KEARNY STREET
Address 2:
City:	SAN FRANCISCO
State:	CA
Zip:	94108
Phone:	248-635-7605
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	415 KEARNY STREET
Address 2:
City:	SAN FRANCISCO
State:	CA
Zip:	94108
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
NIMA GHAMSARI	CEO	287920543	YES		9/1/2018
ERIN COLLARD	CFO	620498475	YES		9/1/2018
GREGORY ISAACS	VICE PRESIDENT	572778668	YES		9/1/2018

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:	SETH GREENSTEIN
Title:	TREASURER & SECRETARY
Phone Number:	856-216-0220
Email Address:	KATIE@WESTMONTLAW.COM