Notification of Changes for Business Entity
General Information
Business Entity Name:	PTZ INSURANCE AGENCY, LTD.
Incorporation / Formation Date:
FEIN:	364431248
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	IL
County:	COOK
Business Address
Address 1:	3315 ALGONQUIN RD., STE. 450
Address 2:
City:	ROLLING MEADOWS
State:	IL
Zip:	60008
Phone:	866-597-2424
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	3315 ALGONQUIN RD., STE. 450
Address 2:
City:	ROLLING MEADOWS
State:	IL
Zip:	60008
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
PATRICE KARWOWSKI	RDA	252802	YES		11/04/2016

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:	CHRISTINE DEWITT
Title:	ACCOUNTING CLERK
Phone Number:	501-664-8044
Email Address:	CDEWITT@CENTRALLICENSINGBUREAU.COM