Notification of Changes for Business Entity
General Information
Business Entity Name:	BREMKE INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	460765211
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	LORAIN
Business Address
Address 1:	104 S MAIN STREET
Address 2:
City:	WELLINGTON
State:	OH
Zip:	44090
Phone:	4406470225
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 393
Address 2:
City:	WELLINGTON
State:	OH
Zip:	44090
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
DEAN BREMKE	AGENT	17312252	YES		07/01/2016

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

Submitted By
Submitted By:	KYLE BREMKE
Title:	PRESIDENT
Phone Number:	4406470225
Email Address:	KYLE@BREMKEINSURANCE.COM