Notification of Changes for Business Entity
General Information
Business Entity Name:	USI INSURANCE SERVICES LLC
Incorporation / Formation Date:
FEIN:	133771734
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	PA
County:	DELAWARE
Business Address
Address 1:	ONE INTERNATIONAL PLAZA
Address 2:	SUITE 400
City:	PHILADELPHIA
State:	PA
Zip:	19113
Phone:	2066767466
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	601 UNION ST SUITE 1000
Address 2:
City:	SEATTLE
State:	WA
Zip:	98101
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
JOHN F TOOSON	PRODUCER	1788957		YES	6/20/2017

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:	MORGAN DIENST
Title:	COMPLIANCE ASSISTANT
Phone Number:	2066767466
Email Address:	LICENSING@USI.COM