Notification of Changes for Business Entity
General Information
Business Entity Name:	JIM SINGER INS AGENCY INC
Incorporation / Formation Date:	010191
FEIN:	311309921
Ohio License Number:	3570
NPN:	1875829
DBA / Trade Name:
State of Domicile:	OH
County:	NOBLE
Business Address
Address 1:	44194 FAIRGROUND RD
Address 2:	PO BOX 256
City:	CALDWELL
State:	OH
Zip:	43724
Phone:	7407322221
Fax:	7407326111
Business Web Site Address:
Business Email Address:	SINGERAUTOSALES@HOTMAIL.COM
Mailing Address
Address 1:	44194 FAIRGROUND RD
Address 2:	PO BOX 256
City:	CALDWELL
State:	OH
Zip:	43724
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:	KRISTA SCHOEPPNER
Title:	OFFICE MANAGER
Phone Number:	7407322221
Email Address:	SINGERAUTOSALES@HOTMAIL.COM