Notification of Changes for Business Entity
General Information
Business Entity Name:	JOHNSON INS SERVICES L L C
Incorporation / Formation Date:
FEIN:	562435265
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	WI
County:	RACINE
Business Address
Address 1:	1103 HUNTER DR
Address 2:
City:	MOUNT PLEASENT
State:	WI
Zip:	53406
Phone:	262-321-2300
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1103 HUNTER DR
Address 2:
City:	MOUNT PLEASENT
State:	WI
Zip:	53406
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
MARK BEHRENS	CHIEF OPERATING OFFICER	390709434	YES		07/30/2018
JOANNE SZYMASZEK	PRESIDENT	392746314	YES		07/30/2018
JEFFERY MARQUARDT	EVP - EMPLOYEE BENEFITS	392823719	YES		07/30/2018
DARLENE JANOWITZ	SVP - DIRECTOR OF OPERATIONS	389845812	YES		07/30/2018
STEVEN SCHILL	SVP - COMMERCIAL LINES PRES.	393821256	YES		07/30/2018

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:	KATIE NEWGARD / LICENSING PROFESSIONALS
Title:	LICENSING SPECIALIST
Phone Number:	8885435432
Email Address:	KNEWGARD@LICENSINGPROS.COM