Notification of Changes for Business Entity
General Information
Business Entity Name:	DCB INSURANCE SERVICES LLC
Incorporation / Formation Date:	10/11/2005
FEIN:	20-3746764
Ohio License Number:	33652
NPN:	8645154
DBA / Trade Name:
State of Domicile:	OH
County:	DELAWARE
Business Address
Address 1:	110 RIVERBEND AVENUE, PO BOX 613
Address 2:
City:	LEWIS CENTER
State:	OH
Zip:	43035
Phone:	740-657-7818
Fax:	740-657-7819
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	110 RIVERBEND AVENUE, PO BOX 613
Address 2:
City:	LEWIS CENTER
State:	OH
Zip:	43035
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
ROGER A. LOSSING	CEO/PRESIDENT	1836233	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)
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:	ROGER A. LOSSING
Title:	CEO
Phone Number:	740-657-7818
Email Address:	RLOSSING@FCBANKING.COM