Notification of Changes for Business Entity
General Information
Business Entity Name:	ED BITZER INS AGENCY INC
Incorporation / Formation Date:
FEIN:	47-2124999
Ohio License Number:	1052814
NPN:	17471665
DBA / Trade Name:
State of Domicile:	OH
County:	BUTLER
Business Address
Address 1:	9017 COLUMBUS CINCINNATI RD
Address 2:
City:	WEST CHESTER
State:	OH
Zip:	45069
Phone:	513-777-5175
Fax:	513-755-5081
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	7318 WINDSOR MEADOW DR
Address 2:
City:	MAINEVILLE
State:	OH
Zip:	45039
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

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:	EDWARD BITZER
Title:	OWNER/AGENT
Phone Number:	513-777-5175
Email Address:	ED.BITZER.B1I6@STATEFARM.COM