Notification of Changes for Business Entity
General Information
Business Entity Name:	CITIGROUP LIFE AGENCY
Incorporation / Formation Date:	04/10/2009
FEIN:	26-4399785
Ohio License Number:	39423
NPN:	13454866
DBA / Trade Name:
State of Domicile:	DE
County:	SUSSEX
Business Address
Address 1:	540 CROSSPOINT PARKWAY
Address 2:
City:	GETZVILLE
State:	NY
Zip:	14068
Phone:	7167308540
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	540 CROSSPOINT PARKWAY
Address 2:
City:	GETZVILLE
State:	NY
Zip:	14068
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
LARA BACON	NON-OFFICER	9427224	YES		05/07/2018

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:	ALEXANDER ROSCHE
Title:	NON-OFFICER
Phone Number:	7167308540
Email Address:	ALEX.ROSCHE@CITI.COM