Notification of Changes for Business Entity
General Information
Business Entity Name:	LFA, LIMITED LIABILITY COMPANY
Incorporation / Formation Date:
FEIN:	352111013
Ohio License Number:
NPN:	3642385
DBA / Trade Name:
State of Domicile:	IN
County:	ALLEN
Business Address
Address 1:	1300 S CLINTON ST
Address 2:
City:	FORT WAYNE
State:	IN
Zip:	46802
Phone:	260-455-2000
Fax:
Business Web Site Address:
Business Email Address:	CORPAGENCYLIC@LFG.COM
Mailing Address
Address 1:	1300 S CLINTON ST
Address 2:
City:	FORT WAYNE
State:	IN
Zip:	46802
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
SCOTT M WITEBY	VICE PRESIDENT	569-63-4687	YES		01/17/2017

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)
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:	CHRIS WALTER
Title:	CORPORATE INSURANCE AGENCY LICENSING CONSULTANT
Phone Number:	260-455-5594
Email Address:	CHRIS.WALTER@LFG.COM