Notification of Changes for Business Entity
General Information
Business Entity Name:	HAYS INSURANCE AGENCIES, LLC.
Incorporation / Formation Date:
FEIN:	34-1380045
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	HARDIN
Business Address
Address 1:	202 S. MAIN ST.
Address 2:
City:	ADA
State:	OH
Zip:	45810
Phone:	4196345626
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 295
Address 2:
City:	ADA
State:	OH
Zip:	45810
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
BRUCE E. HAYS	PREVIOUS OWNER	1832101		YES	01/01/2017
CHAD B. HAYS	NEW OWNER	3239314	YES		01/01/2017

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:	CHAD B. HAYS
Title:	NEW OWNER
Phone Number:	4196345626
Email Address:	CHADHAYS@WCOIL.COM