Notification of Changes for Business Entity
General Information
Business Entity Name:	KEVIN OBRIEN CROP INSURANCE LLC
Incorporation / Formation Date:	09/01/2007
FEIN:	26-0861705
Ohio License Number:	36730
NPN:	9655394
DBA / Trade Name:
State of Domicile:	OH
County:	CHAMPAIGN
Business Address
Address 1:	11570 ROSEDALE RD
Address 2:
City:	MECHANICSBURG
State:	OH
Zip:	43044
Phone:	19378342221
Fax:
Business Web Site Address:
Business Email Address:	RKOBRIEN53@GMAIL.COM
Mailing Address
Address 1:	11570 ROSEDALE RD
Address 2:
City:	MECHANICSBURG
State:	OH
Zip:	43044
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
RYAN MAURICE	AGENT	17834156	YES		06142016

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
KEVIN OBRIEN

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:	ROBERT K OBRIEN
Title:	AGENT/OWNER
Phone Number:	19378342221
Email Address:	RKOBRIEN53@GMAIL.COM