Notification of Changes for Business Entity
General Information
Business Entity Name:	ROBIN FOWLER STATE FARM
Incorporation / Formation Date:	10/01/2015
FEIN:	341842403
Ohio License Number:	1108620
NPN:	1797270
DBA / Trade Name:
State of Domicile:	OH
County:	LAWRENCE
Business Address
Address 1:	212 SOLIDA RD
Address 2:
City:	SOUTH POINT
State:	OH
Zip:	45680
Phone:	7403772346
Fax:
Business Web Site Address:
Business Email Address:	ROBIN.FOWLER.PICH@STATEFARM.COM
Mailing Address
Address 1:	212 SOLIDA RD
Address 2:
City:	SOUTH POINT
State:	OH
Zip:	45680
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	ROBIN FOWLER STATE FARM
New DBA/Trade Name:	YES	New DBA/Trade Name:	ROBIN FOWLER AGENCY
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

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:	ROBIN FOWLER
Title:	OWNER
Phone Number:	7409886371
Email Address:	ROBIN.FOWLER.PICH@STATEFARM.COM