Notification of Changes for Business Entity
General Information
Business Entity Name:	CARL A. LAURIANTI INSURANCE AGENCY, INC.
Incorporation / Formation Date:	05/05/1987
FEIN:	34-1550650
Ohio License Number:	4277
NPN:	1882355
DBA / Trade Name:
State of Domicile:	OH
County:	PORTAGE
Business Address
Address 1:	559 DALEVIEW DRIVE
Address 2:
City:	AURORA
State:	OH
Zip:	44202
Phone:	216-570-0115
Fax:
Business Web Site Address:
Business Email Address:	1CALAURIANTI@WINDSTREAM.NET
Mailing Address
Address 1:	P. O. BOX 229
Address 2:
City:	MACEDONIA
State:	OH
Zip:	44056
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:	CARL A. LAURIANTI
Title:	PRESIDENT
Phone Number:	216-570-0115
Email Address:	1CALAURIANTI@WINDSTREAM.NET