Notification of Changes for Business Entity
General Information
Business Entity Name:	OHIO INS SERVICES INC
Incorporation / Formation Date:
FEIN:	34-0961920
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	ALLEN
Business Address
Address 1:	722 NORTH CABLE ROAD
Address 2:
City:	LIMA
State:	OH
Zip:	45805
Phone:	419-227-6604
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	722 NORTH CABLE ROAD
Address 2:
City:	LIMA
State:	OH
Zip:	45805
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
BENJAMIN E HOOVER	AGENT	1003059		YES	10/4/2016
JAMES H NIEDECKEN	AGENT	967076		YES	10/4/2016

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
JEFFREY A SUNDERHAUS	TREASURER	1003050		YES	10/4/2016
KIM W GILBERT	TREASURER	1003057		YES	10/4/2016

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:	VICKI HALL
Title:	ADMINISTRATIVE ASSISTANT
Phone Number:	419-227-6604
Email Address:	VHALL@AFFINITY-MUTUAL.COM