Notification of Changes for Business Entity
General Information
Business Entity Name:	SIMON FINACIAL SERVICE LLC DBA HEETER INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	204658816
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	PREBLE
Business Address
Address 1:	130 N COMMERCE ST
Address 2:
City:	LEWISBURG
State:	OH
Zip:	45338
Phone:	937-962-2677
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 70
Address 2:
City:	LEWISBURG
State:	OH
Zip:	45338
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
LORRIE E ULLERY	CSR	3241223	YES		04/01/2017

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:	LORRIE E ULLERY
Title:	CSR
Phone Number:	937-962-2677
Email Address:	ULLERY@HEETERINS.COM