Notification of Changes for Business Entity
General Information
Business Entity Name:	STAPLETON GROUP INC.
Incorporation / Formation Date:	07/06/1967
FEIN:	34-1014223
Ohio License Number:	1095
NPN:	2762759
DBA / Trade Name:
State of Domicile:	OH
County:	FULTON
Business Address
Address 1:	122 N. MAIN ST.
Address 2:
City:	SWANTON
State:	OH
Zip:	43558
Phone:	419-720-6446
Fax:	419-882-3911
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 147
Address 2:
City:	SWANTON
State:	OH
Zip:	43558
Indicate the type of change you are seeking
Address Change:	NO
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
JAKE POHJALA	AGENT	17696492	YES		10/01/2015
CHERYL LAFOLLETTE	AGENT	16001180	YES		10/01/2015

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:	JANET TAYLOR
Title:	CORP. SECRETARY
Phone Number:	419-720-6446
Email Address:	JANET@STAPLETONINSURANCE.COM