Notification of Changes for Business Entity
General Information
Business Entity Name:	CROSSROADS CROP INSURANCE LLC
Incorporation / Formation Date:
FEIN:	472539849
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	WYANDOT
Business Address
Address 1:	1086 E WYANDOT AVE
Address 2:
City:	UPPER SANDUSKY
State:	OH
Zip:	43351
Phone:	567-232-1921
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1086 E WYANDOT AVE
Address 2:
City:	UPPER SANDUSKY
State:	OH
Zip:	43351
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
CANDACE WEAVER	AGENT	18233930	YES		01012017
SHELBY BRAMMELL	AGENT	18233809	YES		01012017

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:	KAYLA WEAVER
Title:	OWNER
Phone Number:	567-232-1921
Email Address:	WEAVER.KAYLA@GMAIL.COM