Notification of Changes for Business Entity
General Information
Business Entity Name:	NORMAN G. OLSON INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	61-1609122
Ohio License Number:	41136
NPN:	15649305
DBA / Trade Name:
State of Domicile:	IL
County:	COOK
Business Address
Address 1:	3901 W. 95TH STREET
Address 2:
City:	EVERGREEN PARK
State:	IL
Zip:	60805
Phone:	7086368484
Fax:
Business Web Site Address:
Business Email Address:	SARA.O@OLSON-INS.COM
Mailing Address
Address 1:	3901 W. 95TH STREET
Address 2:
City:	EVERGREEN PARK
State:	IL
Zip:	60805
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	YES	New DBA/Trade Name:	LARRICK DIV OLSON INS GRP
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:	JEFF OLSON
Title:	PRESIDENT
Phone Number:	7086368484
Email Address:	SARA.O@OLSON-INS.COM