Notification of Changes for Business Entity
General Information
Business Entity Name:	PEOPLES INSURANCE AGENCY, LLC
Incorporation / Formation Date:	02/11/1994
FEIN:	31-1398962
Ohio License Number:	2671
NPN:	2212599
DBA / Trade Name:
State of Domicile:	OH
County:	WASHINGTON
Business Address
Address 1:	138 PUTNAM ST
Address 2:
City:	MARIETTA
State:	OH
Zip:	45750
Phone:	740-376-7279
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	138 PUTNAM ST
Address 2:
City:	MARIETTA
State:	OH
Zip:	45750
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
KATHLEEN M RICHARDS	AGENT	8969047		YES	06/14/2016
LORI ANN DIBELLO	AGENT	16900029	YES		06/01/2016

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)
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:	AMY JO MIRACLE
Title:	LICENSING/ACCOUNTING MGR
Phone Number:	740-376-7279
Email Address:	AMYJO.MIRACLE@PEBO.COM