Notification of Changes for Business Entity
General Information
Business Entity Name:	OSB INSURANCE LLC
Incorporation / Formation Date:
FEIN:	262181000
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	DARKE
Business Address
Address 1:	275 W MAIN ST
Address 2:
City:	OSGOOD
State:	OH
Zip:	45351
Phone:	(419) 582-2681
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 69
Address 2:
City:	OSGOOD
State:	OH
Zip:	45351
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
PEGGY DREES	RDA			YES	08/1/2016
AZA BITTINGER	RDA		YES		08/15/2016

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)	YES
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	BANKING

Submitted By
Submitted By:	JAMES SAROSY
Title:	RDA
Phone Number:	614 846 2170
Email Address:	JJSAROSY@CBAO.COM