Notification of Changes for Business Entity
General Information
Business Entity Name:	OLD FORT INSURANCE LLC
Incorporation / Formation Date:
FEIN:	15657979
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	SENACA
Business Address
Address 1:	634 W MARKET STREET
Address 2:
City:	TIFFIN
State:	OH
Zip:	44883
Phone:	4194471600
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	634 W MARKET STREET
Address 2:
City:	TIFFIN
State:	OH
Zip:	44883
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
JAMES SAROSY	RDA			YES	7/13/2018
JAMES HARVIN	RDA	381527384	YES		7/13/2018

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:	AZA BITTINGER
Title:	RDA
Phone Number:	614 846 2238
Email Address:	AHBITTINGER@CBAO.COM