Notification of Changes for Business Entity
General Information
Business Entity Name:	SHISLER INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	34-1345104
Ohio License Number:	1540
NPN:	22113022
DBA / Trade Name:
State of Domicile:	OH
County:	PAULDING
Business Address
Address 1:	112 W JACKSON ST
Address 2:
City:	PAULDING
State:	OH
Zip:	45879
Phone:	419-399-5121
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	112 W JACKSON ST
Address 2:	P.O. BOX 269
City:	PAULDING
State:	OH
Zip:	45879
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
CASSANDRA VANCE	AGENT	8798855	YES		03/27/2015
TIFFANY WILCOX	CSR	17229629		YES	12/31/2017

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)
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:	RANDY MYERS
Title:	PRESIDENT
Phone Number:	419-238-7880
Email Address:	RMYERS@LELANDSMITH.COM