Notification of Changes for Business Entity
General Information
Business Entity Name:	HOLLOWAY INSURANCE, INC.
Incorporation / Formation Date:
FEIN:	34-1331867
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	COLUMBIANA
Business Address
Address 1:	105 S MAIN ST
Address 2:
City:	COLUMBIANA
State:	OH
Zip:	44408
Phone:	3304823385
Fax:	3304829823
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 28
Address 2:
City:	COLUMBIANA
State:	OH
Zip:	44408
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
BARBARA LOUISE CHEVALIER	AGENT	2493971		YES	01/01/2015
CHARLES E BOOMS	AGENT	8186524		YES	01/01/2015
CLAUDIA M ARNETTE	AGENT	1772011		YES	01/01/2015
DAVID M PATTERSON	EMPLOYEE	1736879		YES	01/01/2015
DENISE J BOOMS	AGENT	2514977		YES	01/01/2015
JACK L MILLS, JR.	EMPLOYEE	519493		YES	01/01/2015
JACK L MILLS, JR.	PRESIDENT	519493		YES	01/01/2015
JOHN D GAURON	VICE PRESIDENT	1840558		YES	01/01/2015
JULIA L PUNCH	AGENT	1720050		YES	01/01/2015
LINDA L WINTERS	AGENT	1831696		YES	05/31/2016
LINDA L EELLS	AGENT	1783248		YES	01/01/2015
MELODY K KRAFT	AGENT	1792353		YES	08/27/2015
RALPH R GUAPPONE	AGENT	1863770		YES	01/01/2015
WAYNE L BAUER	EMPLOYEE	1781468		YES	01/01/2015
WAYNE L BAUER	AGENT	1781468		YES	01/01/2015

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:	JESSICA HOLLOWAY
Title:	TREASURER
Phone Number:	330-482-3385
Email Address:	JESSICA@HOLLOWAY-INSURANCE.COM