Notification of Changes for Business Entity
General Information
Business Entity Name:	KORN-O'NEILL INSURANCE AGENCY, INC.
Incorporation / Formation Date:	01/01/1958
FEIN:	310530448
Ohio License Number:	2711
NPN:	1929190
DBA / Trade Name:
State of Domicile:	OH
County:	FAYETTE
Business Address
Address 1:	9 FAYETTE CENTER
Address 2:	P.O. BOX 519
City:	WASHINGTON COURT HOUSE
State:	OH
Zip:	43160
Phone:	7403353030
Fax:	7403353084
Business Web Site Address:	WWW.KORNONEILL.COM
Business Email Address:	MTO1301@HOTMAIL.COM
Mailing Address
Address 1:	9 FAYETTE CENTER
Address 2:	P.O. BOX 519
City:	WASHINGTON COURT HOUSE
State:	OH
Zip:	43160
Indicate the type of change you are seeking
Address Change:	YES
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:	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:	MICHAEL T. O'NEILL
Title:	PRESIDENT
Phone Number:	7403353030
Email Address:	MTO1301@HOTMAIL.COM