Notification of Changes for Business Entity
General Information
Business Entity Name:	GEICO INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	521168724
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	MD
County:	MONTGOMERY
Business Address
Address 1:	5260 WESTERN AVENUE
Address 2:
City:	CHEVY CHASE
State:	MD
Zip:	20815
Phone:	5402867132
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	ONEGEICO BLVD
Address 2:	LICENSING 2ND FLOOR
City:	FREDERICKSBURG
State:	VA
Zip:	22412
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
SEAN PADDOCK	AGENT	17200403	YES		5/9/17
DAVID NIEDZIELSKI, JR.	AGENT	18383216	YES		5/9/17
TIMOTHY WEAVER	AGENT	18383194	YES		5/9/17
NAFACIA WALLACE	AGENT	18384440	YES		5/9/17
ALYSSA VASQUEZ	AGENT	18383223	YES		5/9/17
JACOB STANLEY	AGENT	18383235	YES		5/9/17
NICHOLAS PUFFER	AGENT	18384410	YES		5/9/17
AMANDA STADLMEIR	AGENT	18384423	YES		5/9/17
KAYLA PAPOVICH	AGENT	18383202	YES		5/9/17
ANTHONY MECCA	AGENT	18383221	YES		5/9/17
JOSEPH MARTIN	AGENT	18383227	YES		5/9/17
CHRISTOPHER MARTIN	AGENT	18383220	YES		5/9/17
MERISSA LOOS	AGENT	18383215	YES		5/9/17
GRANT KARLSON	AGENT	18383233	YES		5/9/17
SHARON HUNTER	AGENT	18383175	YES		5/9/17

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:	CHRISTINE KOZIOL
Title:	LICENSING TECHNICIAN
Phone Number:	7162764480
Email Address:	LICENSINGR8@GEICO.COM