Notification of Changes for Business Entity
General Information
Business Entity Name:	STEVE MARSHALL INSURANCE AGENCY, INC
Incorporation / Formation Date:	09/28/2014
FEIN:	471778187
Ohio License Number:	1049383
NPN:	17438978
DBA / Trade Name:
State of Domicile:	OH
County:	OH
Business Address
Address 1:	790 LAFAYETTE RD STE 4
Address 2:
City:	MEDINA
State:	OH
Zip:	44256
Phone:	330-591-4211
Fax:	330-722-1959
Business Web Site Address:	WWW.FARMERSAGENT.COM/SMARSHALL
Business Email Address:	SMARSHALL@FARMERSAGENT.COM
Mailing Address
Address 1:	790 LAFAYETTE RD STE 4
Address 2:
City:	MEDINA
State:	OH
Zip:	44256
Indicate the type of change you are seeking
Address Change:	YES
Business Entity Name Change:	YES	Old Business Entity Name:	445 W LIBERTY, MEDINA, OH 442
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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

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