Notification of Changes for Business Entity
General Information
Business Entity Name:	THE MODERN INSURANCE STORE
Incorporation / Formation Date:
FEIN:	463244413
Ohio License Number:	997107
NPN:	17016829
DBA / Trade Name:
State of Domicile:	OH
County:	CLERMONT
Business Address
Address 1:	2 HOGAN DR
Address 2:
City:	MILFORD
State:	OH
Zip:	45150
Phone:	5133685694
Fax:
Business Web Site Address:
Business Email Address:	JOHNDANIELFARLOW@GMAIL.COM
Mailing Address
Address 1:	2 HOGAN DR
Address 2:
City:	MILFORD
State:	OH
Zip:	45150
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	NORTHRIDGE INSURANCE GROUP
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)	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?	NO
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:	JOHN FARLOW
Title:	OWNER
Phone Number:	5133685694
Email Address:	JOHNDANIELFARLOW@GMAIL.COM