Notification of Changes for Business Entity
General Information
Business Entity Name:	WATSON INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	46-0682927
Ohio License Number:	968390
NPN:	16756885
DBA / Trade Name:
State of Domicile:	OH
County:	CHAMPAIGN
Business Address
Address 1:	20 EAST MAPLE ST.
Address 2:
City:	NORTH LEWISBURG
State:	OH
Zip:	43060
Phone:	937-747-2400
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 265
Address 2:
City:	NORTH LEWISBURG
State:	OH
Zip:	43060
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	SUMMERFIELD & WATSON INSURANCE
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:	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)	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:	JENNIFER WATSON
Title:	OWNER
Phone Number:	937-747-2400
Email Address:	JENNIFER@SUMMERFIELDWATSON.COM