Notification of Changes for Business Entity
General Information
Business Entity Name:	SERGAKIS & ASSOCIATES AGENCY, INC.
Incorporation / Formation Date:	11/20/2015
FEIN:	810771762
Ohio License Number:	1098675
NPN:	17879250
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	4942 REED RD
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43220
Phone:	6145451510
Fax:
Business Web Site Address:
Business Email Address:	SERGAKM@NATIONWIDE.COM
Mailing Address
Address 1:	4942 REED RD
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43220
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)	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?	YES
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement	PROPERTY RENTALS

Submitted By
Submitted By:	MICHAEL SERGAKIS
Title:	OWNER/PRESIDENT
Phone Number:	6145451510
Email Address:	SERGAKM@NATIONWIDE.COM