Notification of Changes for Business Entity
General Information
Business Entity Name:	BLOOM INSURANCE AGENCY, LLC
Incorporation / Formation Date:	07172017
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
ERVIN, ANTHONY	AGENT	17755758	YES		10/15/2017
HLAD, KENNETH	AGENT	3515643	YES		10/15/2017
HOWELL, KRISTEN	AGENT	17703012	YES		10/15/2017
FAULKNER, TRACY	AGENT	18085069	YES		10/15/2017
JOHNSON, BENJAMIN	AGENT	15670258	YES		10/15/2017
JOHNSTONE, ROBERT	AGENT	3241298	YES		10/15/2017
WRIGHT, GERALD	AGENT	12762085	YES		10/15/2017
CRAMER, MATTHEW	AGENT	9131584	YES		10/15/2017
SAMPSON, MICHAEL	AGENT	1891170	YES		10/15/2017
CARMICHAEL, STEVEN	AGENT	3102697	YES		10/15/2017
DOYLE, MICHAEL	AGENT	16977078	YES		10/15/2017
EMERSON, BRYAN	AGENT	18055889	YES		10/15/2017
LUPI, AMANDA	AGENT	16779141	YES		10/15/2017
NIGHMAN, TONYA	AGENT	17957014	YES		10/15/2017
SPRADLIN, WADE	AGENT	18519179	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