Notification of Changes for Business Entity
General Information
Business Entity Name:	BLOOM INSURANCE AGENCY, LLC
Incorporation / Formation Date:	07/17/2007
FEIN:	260640936
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:	8129612535
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
MARY LAFEVER	AGENT	17181155		YES	04/14/2016

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 L PEARCE
Title:	SVP
Phone Number:	8129612535
Email Address:	LICENSING@BLOOMINSURANCEAGENCY.COM