Notification of Changes for Business Entity
General Information
Business Entity Name:	DAVID ERIC WAGGONER INSURANCE AGENCY
Incorporation / Formation Date:	11/17/2015
FEIN:	47-5408346
Ohio License Number:	1088115
NPN:	17781056
DBA / Trade Name:
State of Domicile:	OH
County:	JEFFERSON
Business Address
Address 1:	1028 MAIN ST
Address 2:
City:	FOLLANSBEE
State:	WV
Zip:	26037
Phone:	304-527-2175
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 577
Address 2:
City:	FOLLANSBEE
State:	WV
Zip:	26037
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
CATHY L RIHEL	OFFICE STAFF	7001385	YES		01-15-2016
CAROL S BREEN	OFFICE STAFF	17835430	YES		01-15-2016
AMBER L TESTER	OFFICE STAFF	235-37-3462	YES		01-15-2016

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:	DAVID ERIC WAGGONER
Title:	OWNER
Phone Number:	304-527-2175
Email Address:	ERIC.WAGGONER.F23G@STATEFARM.COM