Notification of Changes for Business Entity
General Information
Business Entity Name:	HUMMEL GROUP, INC.
Incorporation / Formation Date:
FEIN:	341096613
Ohio License Number:	2443
NPN:	2255938
DBA / Trade Name:
State of Domicile:	OH
County:	HOLMES
Business Address
Address 1:	4585 STATE ROUTE 39
Address 2:
City:	BERLIN
State:	OH
Zip:	44610
Phone:	330-893-2600
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 250
Address 2:
City:	BERLIN
State:	OH
Zip:	44610
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
SAVANNAH YODER	AGENT	18159962	YES		10/21/2016

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)	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:	VAUGHN TROYER
Title:	PRESIDENT
Phone Number:	330-893-2600
Email Address:	VTROYER@HUMMELGRP.COM