Notification of Changes for Business Entity
General Information
Business Entity Name:	BUREN INSURANCE GROUP INC
Incorporation / Formation Date:
FEIN:	341237066
Ohio License Number:	4594
NPN:	2216429
DBA / Trade Name:
State of Domicile:	OH
County:	ASHLAND
Business Address
Address 1:	1101 SUGARBUSH DRIVE
Address 2:
City:	ASHLAND
State:	OH
Zip:	44805
Phone:	4192818060
Fax:	4192817119
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1101 SUGARBUSH DRIVE
Address 2:
City:	ASHLAND
State:	OH
Zip:	44805
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
SARAH ANN CHRISTIE	ACCOUNT ASSOCIATE	17958988	YES		6/2/2016
KAITLIN B PINKERTON	PERSONAL SALES CONSULTANT	17977060	YES		6/21/2016
DAVID CHRISTOPHER STUART	ACCOUNT EXECUTIVE	9241599	YES		6/6/2016

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:	BECKY WOLLESON
Title:	INSURANCE OPERATIONS MANAGER
Phone Number:	419-281-8060
Email Address:	BECKY.WOLLESON@BURENINSURANCEGROUP.COM