| Entity Name: | MID MOUNTAIN INSURANCE AGENCY, LLC |
| Jurisdiction: | Connecticut |
| Legal type: | LLC |
| Citizenship: | Foreign |
| Status: | Active |
| Sub status: | Annual report due |
| Date Formed: | 29 Dec 2008 |
| Business ALEI: | 0958736 |
| Annual report due: | 31 Mar 2025 |
| NAICS code: | 524210 - Insurance Agencies and Brokerages |
| Mailing address: | 10751 DEERWOOD PARK BLVD SUITE 200, JACKSONVILLE, FL, United States, 32256 |
| Office jurisdiction address: | 1500 NW Bethany Blvd., Ste. 200, Beaverton, OR, 97006, United States |
| Business address: | 9635 M STREET, OMAHA, NE, 68127, United States |
| Place of Formation: | OREGON |
| E-Mail: | mscrivner@fortegra.com |
| Name | Role |
|---|---|
| CORPORATE CREATIONS NETWORK INC. | Agent |
| Name | Role | Business address | Residence address |
|---|---|---|---|
| MICHAEL VRBAN | Officer | 10751 DEERWOOD PARK BLVD, SUITE 200, JACKSONVILLE, FL, 32256, United States | 221 CLEARLAKE DR., PONTE VEDRA BEACH, FL, 32082, United States |
| Edward Pena | Officer | No data | 10751 Deerwood Park Blvd., Ste.200, JACKSONVILLE, FL, 32256, United States |
| RICHARD KAHLBAUGH | Officer | 10751 DEERWOOD PARK BLVD, SUITE 200, JACKSONVILLE, FL, 32256, United States | 25330 MARSH LANDING PARKWAY, PONTE VEDRA BEACH, FL, 32082, United States |
| John Short | Officer | 10751 Deerwood Park Blvd Ste 200, Jacksonville, FL, 32256-4836, United States | 10751 Deerwood Park Blvd Ste 200, Jacksonville, FL, 32256-4836, United States |
| LOTS INTERMEDIATE CO. | Officer | 10751 DEERWOOD PARK BLVD, SUITE 200, JACKSONVILLE, FL, 32256, United States | 10751 DEERWOOD PARK BLVD, SUITE 200, JACKSONVILLE, FL, 32256, United States |
| Type | Old value | New value | Date of change |
|---|---|---|---|
| Name change | PACIFIC BENEFITS GROUP NORTHWEST, L.L.C. | MID MOUNTAIN INSURANCE AGENCY, LLC | 2024-12-30 |
| Filing number | Filing date | Effective date | Filing category | Filing type | Report year |
|---|---|---|---|---|---|
| BF-0013262500 | 2024-12-30 | 2024-12-30 | Amendment | Amendment of Foreign Registration Statement | No data |
| BF-0012303647 | 2024-02-15 | No data | Annual Report | Annual Report | No data |
| BF-0011290615 | 2023-02-07 | No data | Annual Report | Annual Report | No data |
| BF-0010302330 | 2022-02-16 | No data | Annual Report | Annual Report | 2022 |
| 0007163255 | 2021-02-16 | No data | Annual Report | Annual Report | 2021 |
| 0007034413 | 2020-12-09 | 2020-12-09 | Change of Business Address | Business Address Change | No data |
| 0006736668 | 2020-01-30 | No data | Annual Report | Annual Report | 2020 |
| 0006427222 | 2019-03-06 | No data | Annual Report | Annual Report | 2019 |
| 0006242958 | 2018-09-06 | 2018-09-06 | Change of Agent Address | Agent Address Change | No data |
| 0006195097 | 2018-06-04 | 2018-06-04 | Change of Agent | Agent Change | No data |
Date of last update: 20 Jan 2025
Sources: Connecticut's Official State Website
