Notification of Changes for Business Entity
General Information
Business Entity Name:	AMERICAN CASUALTY INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	311551284
Ohio License Number:
NPN:	2487
DBA / Trade Name:
State of Domicile:	OH
County:	LUCAS
Business Address
Address 1:	6060 RENAISSANCE PLACE SUITE I
Address 2:
City:	TOLEDO
State:	OH
Zip:	43623
Phone:	419-885-3571
Fax:	419-885-0217
Business Web Site Address:	WWW.AMERICANCASUALTYINS.COM
Business Email Address:	DLIGHT@BEX.NET
Mailing Address
Address 1:	6060 RENAISSANCE PL SUITE I
Address 2:
City:	TOLEDO
State:	OH
Zip:	43623
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
BRITTANY KOLLING	AGENT	1190180	YES		05032018

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:	DIANE LIGHT
Title:	PRESIDENT
Phone Number:	419-885-3571
Email Address:	DLIGTH@BEX.NET