Notification of Changes for Business Entity
General Information
Business Entity Name:	KEYCORP INSURANCE AGENCY USA, INC.
Incorporation / Formation Date:
FEIN:	34/1348300
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	USA
Business Address
Address 1:	4900 TIEDEMAN RD
Address 2:
City:	BROOKLYN
State:	OH
Zip:	44144
Phone:	216.813.7904
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	4900 TIEDEMAN RD
Address 2:
City:	BROOKLYN
State:	OH
Zip:	44144
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
EMILY GIEL	AGENT	17263564	YES		05/25/2018
SEANTELE RUSNAK	AGENT	17564055	YES		05/25/2018

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)	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:	JOANN DETZEL
Title:	LICENSE SPECIALIST
Phone Number:	216.813.7904
Email Address: