Notification of Changes for Business Entity
General Information
Business Entity Name:	ENERGY INS AGENCY INC
Incorporation / Formation Date:
FEIN:	61-4004028
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	KY
County:	FAYETTE
Business Address
Address 1:	3008 ATKINSON AVE
Address 2:
City:	LEXINGTON
State:	KY
Zip:	40509
Phone:	859-273-1549
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P O BOX 55268
Address 2:
City:	LEXINGTON
State:	KY
Zip:	40555
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
LINDA PERRY	AGENT	2342345	YES		07/16/2018
LYNN PLONA	AGENT	1836680	YES		07/30/2018
JOYCE LIESKE	AGENT	2207429		YES	07/01/2018
MATTHEW TREVOR BOTTS	AGENT	17881183		YES	07/01/2018
DANIEL THOMAS AUTENRIEB	AGENT	8878822		YES	07/01/2018
JERRI REICH	AGENT	17553786	YES		07/01/2018
SUSAN SIEGMAN	AGENT	1725972	YES		07/01/2018

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:	LEA ANN COLEMAN
Title:	BUSINESS OPERATIONS
Phone Number:	859-273-1549
Email Address:	LCOLEMAN@ENERGYINSAGENCY.COM