Notification of Changes for Business Entity
General Information
Business Entity Name:	THE WAYNE AGENCY CO.
Incorporation / Formation Date:
FEIN:	34-0605970
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	SUMMIT
Business Address
Address 1:	2044 SECOND ST.
Address 2:
City:	CUYAHOGA FALLS
State:	OH
Zip:	44221
Phone:	330 928-1104
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P. O. BOX 308
Address 2:
City:	CUYAHOGA FALLS
State:	OH
Zip:	44222
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
BRIAN BAJENSKI	PRODUCER	18799219	YES		07/31/2018

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:	THOMAS L. BUTTERMORE
Title:	VICE PRESIDENT
Phone Number:	330 928-1104
Email Address:	TBUTTERMORE@WAYNEAGENCY.COM