Notification of Changes for Business Entity
General Information
Business Entity Name:	RATHWEG INSURANCE ASSOCIATES
Incorporation / Formation Date:
FEIN:	310792879
Ohio License Number:	1749
NPN:	2760183
DBA / Trade Name:
State of Domicile:	OH
County:	MONTGOMERY
Business Address
Address 1:	2212 S PATTERSON BLVD
Address 2:
City:	DAYTON
State:	OH
Zip:	45409
Phone:	937-296-9393
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	2212 S PATTERSON BLVD
Address 2:
City:	DAYTON
State:	OH
Zip:	45409
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
COURTNEY RATHWEG	PRODUCER	17720277	YES		05/10/2017
RACHEL BARGER	CSR	17847783	YES		05/10/2017
DOUGLAS A HAMMELL	PRODUCER	1475127	YES		05/10/2017
LAURA BRILEY	CSR	16896171	YES		05/10/2017
HEATHER L WOOLLARD	DIRECTOR	000000		YES	05/10/2017
ANNA JAYE WESTFALL	SECRETARY	000000		YES	05/10/2017

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)	NO
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?	NO
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:	PHILIP A RATHWEG JR
Title:	PRESIDENT
Phone Number:	9372969393
Email Address:	ANDREWR@RATHWEGINSURANCE.COM