Notification of Changes for Business Entity
General Information
Business Entity Name:	VGM INSURANCE SERVICES INC
Incorporation / Formation Date:	02/13/2012
FEIN:	45-4564147
Ohio License Number:
NPN:	16609528
DBA / Trade Name:
State of Domicile:	IA
County:	BLACK HAWK
Business Address
Address 1:	111 WEST SAN MARNAN DRIVE
Address 2:
City:	WATERLOO
State:	IA
Zip:	50701
Phone:	3192356656
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 1328
Address 2:
City:	WATERLOO
State:	IA
Zip:	50704
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	YES	New DBA/Trade Name:	CALDWELL INS.
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

Submitted By
Submitted By:	CSC
Title:	AUTHORIZED SUBMITTER
Phone Number:	800-927-9801
Email Address:	BLINSURANCE@CSCGLOBAL.COM