Notification of Changes for Business Entity
General Information
Business Entity Name:	PAYCOR INSURANCE AGENCY, LLC
Incorporation / Formation Date:	01/06/2011
FEIN:	27-4523318
Ohio License Number:	42146
NPN:	16134451
DBA / Trade Name:
State of Domicile:	OH
County:	HAMILTON
Business Address
Address 1:	4811 MONTGOMERY ROAD
Address 2:
City:	CINCINNATI
State:	OH
Zip:	45212
Phone:	513-381-0505
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	4811 MONTGOMERY ROAD
Address 2:
City:	CINCINNATI
State:	OH
Zip:	45212
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
FRANCIS B. NIEHAUS	DRLP	1163293	YES		4/26/2018

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)
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:	ERIN RANLY
Title:	SENIOR CONTRACTS ADMINISTRATOR
Phone Number:	513-954-7308
Email Address:	LEGAL@PAYCOR.COM