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		3/31/2028
Active	Non Resident	Agent	Casualty	8/24/2017		3/31/2028
Inactive	Non Resident	Agent	Life	12/1/2016	10/15/2021
Inactive	Non Resident	Agent	Health	11/17/2016	4/11/2022
Active	Non Resident	Surplus Lines Broker	Not Applicable	12/9/2021		3/31/2028
* If a status Is Pending, Pending Replacement,Or the record displays Affidavit On File, click On them For more details.

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