Notification of Changes for Business Entity
General Information
Business Entity Name:	JIM MCKINNEY INS AGENCY INC
Incorporation / Formation Date:	10-11-2012
FEIN:	34153826
Ohio License Number:	974436
NPN:	16804794
DBA / Trade Name:
State of Domicile:	OH
County:	STARK
Business Address
Address 1:	4555 EVERHARD RD NW
Address 2:
City:	CANTON
State:	OH
Zip:	44718
Phone:	330-494-7400
Fax:	330-494-7404
Business Web Site Address:	JIMMCK.COM
Business Email Address:	JIM@JIMMCK.COM
Mailing Address
Address 1:	4555 EVERHARD RD NW
Address 2:
City:	CANTON
State:	OH
Zip:	44718
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

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