Notification of Changes for Business Entity
General Information
Business Entity Name:	WALLACE & TURNER, INC.
Incorporation / Formation Date:
FEIN:	31-1396641
Ohio License Number:	25046
NPN:	3662390
DBA / Trade Name:
State of Domicile:	OH
County:	CLARK
Business Address
Address 1:	30 WARDER STREET #200
Address 2:
City:	SPRINGFIELD
State:	OH
Zip:	45504
Phone:	937-324-8492
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P O BOX 209
Address 2:
City:	SPRINGFIELD
State:	OH
Zip:	45501
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
TIA D KEITH	ACCOUNT MANAGER	18727952	YES		03/15/2018

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:	PETER J MILLER
Title:	VICE PRESIDENT
Phone Number:	937-324-8492
Email Address:	PMILLER@WTINS.COM