Notification of Changes for Business Entity
General Information
Business Entity Name:	AVON DIXON AGENCY LLC
Incorporation / Formation Date:
FEIN:	800032628
Ohio License Number:	33490
NPN:	7112619
DBA / Trade Name:	JACK MARTIN & ASSOCIATES, INC.
State of Domicile:	MD
County:	TALBOT
Business Address
Address 1:	28640 MARYS COURT, SUITE 100
Address 2:	PO BOX 1588
City:	EASTON
State:	MD
Zip:	21601
Phone:	4108220506
Fax:	4107705402
Business Web Site Address:
Business Email Address:	LICENSING@AVONDIXON.COM
Mailing Address
Address 1:	PO BOX 1588
Address 2:
City:	EASTON
State:	MD
Zip:	21601
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	JOANN C. DUVALL
Title:	DIRECTOR OF TRAINING
Phone Number:	41082280506
Email Address:	LICENSING@AVONDIXON.COM