Notification of Changes for Business Entity
General Information
Business Entity Name:	WYATT INSURANCE GROUP INC
Incorporation / Formation Date:
FEIN:	27-1321215
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	MONTGOMERY
Business Address
Address 1:	5446 WEIDNER ROAD
Address 2:
City:	SPRINGBORO
State:	OH
Zip:	45066
Phone:	9377480358
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	5446 WEIDNER ROAD
Address 2:
City:	SPRINGBORO
State:	OH
Zip:	45066
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
RICHARD W WYATT	PRESIDENT	2211224	YES		01/02/2017
KIMBERLY ANN WYATT	CUSTOMER SERVICE REP	10397692	YES		01/02/2017
ESTHER LEVY KEOUGH	MANAGER	9745479	YES		01/02/2017
KELLY D HOOVER	MANAGER	2256290	YES		01/02/2017
KELLY ANN WINKLER	CUSTOMER SERVICE REP	16714577	YES		01/02/2017
CLAUDIA LEWIS	CUSTOMER SERVICE REP	2223544	YES		01/02/2017
JESSEKA M LAZZARO	CUSTOMER SERVICE REP	17718801	YES		01/02/2017
LU ANN H HOUK	CUSTOMER SERVICE REP	3243098	YES		01/02/2017
CHRISTOPHER CODY MALOTT	CUSTOMER SERVICE REP	16110397	YES		01/02/2017
JODY BRYAN MONTGOMERY	SALES REP	15344130	YES		01/02/2017
FRED LEWIS	FINANCIAL SERVICES REP	1741974	YES		01/02/2017

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:	RICHARD W WYATT
Title:	PRESIDENT
Phone Number:	9377480358
Email Address:	WYATTK4@NATIONWIDE.COM