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Ohio Department of Insurance Agent / Agency Services

Notification of Changes for Business Entity
Complete all required fields below. Required fields are marked with an *.
 
     General Information
Business Entity Name:*  
Incorporation/Formation Date (mm/dd/yyyy):  

FEIN: *

  
Ohio License Number:  
NPN (National Producer Number):  
DBA/Trade Name (if applicable):  
State of Domicile:  

County: *

  
Ohio Sec of State Registration #:  
Business Address 1: *  
Address 2:  
City: *  
State: *
   Zip: *  
Phone: *  
Fax:     
  
Business Web Site  
Business Email:  
Mailing Address 1: *  
Mailing Address 2:  
City: *  
State: *
  
Zip: *
  
Indicate the type of change(s) you are seeking (select all that apply):
Address Change:
  
 
Business Entity Name Change:
 Enter Old Business Entity Name:
 
Add New DBA/Trade Name:
 Enter New DBA/Trade Name:
 
Amend DBA/Trade Name:
 Enter Old DBA/Trade Name:
 
Add or Delete Producers, Members, Owners, Partners, Officers and/or Directors:
  
  Licensed Producers (List only additions or deletions) - Name, Title, Identifying #, Add or Delete, and Eff. Date are required for each entry.
Valid Identifying numbers include:
  1. NPN (National Producer Number) - If licensed person
  2. Complete SSN - If non-licensed person
  3. FEIN - If business entity
Click here to look up an NPN.		  
 
 
Name
Title
Identifying #
 Add 
 Delete
Eff. Date
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Members, Owners, Partners, Officers and Directors
Identify changes for members, owners, partners, officers and directors of business entity. Name, Title, Identifying #, Add or Delete, and Eff. Date are required for each entry.
Valid Identifying numbers include:
  1. NPN (National Producer Number) - If licensed person
  2. Complete SSN - If non-licensed person
  3. FEIN - If business entity
  
 
Name
Title
Identifying #
 Add 
 Delete
Eff. Date
 
 
 
 
 
 
 
 
 
 
Title Business Entity 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) Yes
No
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? Yes
No
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement
Applicant's Certification and Attestation
  I certify that I am an officer, director, principal or partner of the business entity, or member or manager of a limited liability company; and that all of the information submitted in this application and attachments is true and complete. I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity to civil or criminal penalties.
   
Please note:
  Please contact the Department at 614-644-2665 for instructions for the following types of changes:
  • Tax ID number change
  • Surrender of license
  • Merger of business entities
Submitted By: *  
Title: *  
Phone Number: *  
Email Address: *  
 
 

The State of Ohio is an Equal Opportunity Employer

50 W. Town Street, Third Floor - Suite 300   Columbus, Ohio   43215
General Info: 614-644-2658  |  Consumer Hotline: 800-686-1526  |  Fraud Hotline: 800-686-1527  |  OSHIIP Hotline: 800-686-1578