Notification of Changes for Business Entity
General Information
Business Entity Name:	WHITAKER MYERS INSURANCE GROUP
Incorporation / Formation Date:	03/13/1970
FEIN:	341050214
Ohio License Number:	1395
NPN:	957595
DBA / Trade Name:
State of Domicile:	OH
County:	WAYNE
Business Address
Address 1:	3524 COMMERCE PARKWAY
Address 2:
City:	WOOSTER
State:	OH
Zip:	44691
Phone:	330-345-3927
Fax:	330-345-7409
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	3524 COMMERCE PARKWAY
Address 2:
City:	WOOSTER
State:	OH
Zip:	44691
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
ELIZABETH WALTON	CSR	18301949		YES	4/12/17

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)	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

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