DEPARTMENT OF INSURANCE

PUBLIC PROTECTION
CABINET

DEPARTMENT OF INSURANCE

Affiliations

Name	ICM Insurance Service LLC	DOIID	937342	NAIC NPN	18197665

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Active	Non Resident	Agent	Property	8/24/2017		3/31/2026
Active	Non Resident	Agent	Casualty	8/24/2017		3/31/2026
Inactive	Non Resident	Agent	Health	11/17/2016	4/11/2022
Inactive	Non Resident	Agent	Life	12/1/2016	10/15/2021
Active	Non Resident	Surplus Lines Broker	Not Applicable	12/9/2021		3/31/2026
* If a status Is Pending, Pending Replacement,Or the record displays Affidavit On File, click On them For more details.

License Renewal Information

Class	Invoice Date	Response Due / Expiration Date	Response Received Date	Payment Received Date	Renewal Complete
Agent	01/15/2026	03/31/2026
Surplus Lines Broker	01/15/2026	03/31/2026

Appointments with the following Insurers

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	American Family Life Assurance Company of Columbus (AFLAC)	301781	Agent - Health	7/6/2017	4/11/2022
Inactive	American Family Life Assurance Company of Columbus (AFLAC)	301781	Agent - Life	7/6/2017	10/15/2021
Inactive	Atlantic Specialty Insurance Company	518595	Agent - Casualty	9/11/2017	3/28/2019
Inactive	Atlantic Specialty Insurance Company	518595	Agent - Property	9/11/2017	3/28/2019
Active	Independence American Insurance Company	524747	Agent - Casualty	11/10/2023
Active	Independence American Insurance Company	524747	Agent - Property	11/10/2023
Active	United States Fire Insurance Company	582240	Agent - Casualty	7/7/2020
Active	United States Fire Insurance Company	582240	Agent - Property	10/28/2020

Designated Individuals

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Atkielski, Roman David	1138666	Agent - Casualty	12/1/2021	4/11/2022
Inactive	Atkielski, Roman David	1138666	Agent - Health	12/1/2021	4/11/2022
Inactive	Atkielski, Roman David	1138666	Agent - Property	12/1/2021	4/11/2022
Inactive	Atkielski, Roman David	1138666	Surplus Lines Broker - Not Applicable	12/9/2021	4/11/2022
Active	Coxsey, Sarah Elizabeth	1193781	Agent - Casualty	4/21/2022
Denied	Coxsey, Sarah Elizabeth	1193781	Agent - Health
Active	Coxsey, Sarah Elizabeth	1193781	Agent - Property	4/21/2022
Active	Coxsey, Sarah Elizabeth	1193781	Surplus Lines Broker - Not Applicable	4/11/2022
Inactive	Stultz, Greg Graham	930981	Agent - Casualty	8/24/2017	12/1/2021
Inactive	Stultz, Greg Graham	930981	Agent - Health	11/17/2016	12/1/2021
Inactive	Stultz, Greg Graham	930981	Agent - Life	12/1/2016	10/15/2021
Inactive	Stultz, Greg Graham	930981	Agent - Property	8/24/2017	12/1/2021
Inactive	Stultz, Greg Graham	930981	Surplus Lines Broker - Not Applicable	4/16/2021	8/11/2021