Notification of Changes for Business Entity
General Information
Business Entity Name:	INSURANCE OFFICE OF CENTRAL OHIO
Incorporation / Formation Date:
FEIN:	31-1026990
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	165 WEST MAIN STREET
Address 2:
City:	NEW ALBANY
State:	OH
Zip:	46054
Phone:	(614) 939-5471
Fax:	(614) 939-5451
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P. O. BOX 780
Address 2:
City:	NEW ALBANY
State:	OH
Zip:	43054-0789
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
KELLY D. NORVIEL	AGENT	3238583		YES	04/20/2016

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:	IRENE F. LONG
Title:	ADMINISTRATIVE ASSISTANT
Phone Number:	(614) 939-5471
Email Address:	IRENE@IOCO-COLUMBUS.COM