Notification of Changes for Business Entity
General Information
Business Entity Name:	RUESE INSURANCE AGENCY, INC
Incorporation / Formation Date:
FEIN:	31-1440171
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	SHELBY
Business Address
Address 1:	100 S. MAIN AVENUE
Address 2:	SUITE 200
City:	SIDNEY
State:	OH
Zip:	45365
Phone:	937-498-4586
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	100 S. MAIN AVENUE
Address 2:	SUITE 200
City:	SIDNEY
State:	OH
Zip:	45365
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
MACHELLE L BURDEN	CSR	8373501	YES		2/26/2018

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:	RALPH KEISTER III
Title:	PRESIDENT
Phone Number:	937-498-4586
Email Address:	RKEISTER@RUESEINSURANCE.COM