Notification of Changes for Business Entity
General Information
Business Entity Name:	MURFIN INSURANCE AGENCY, INC.
Incorporation / Formation Date:	08/11/1971
FEIN:	31-0802142
Ohio License Number:	4269
NPN:	2212365
DBA / Trade Name:
State of Domicile:	OH
County:	SCIOTO
Business Address
Address 1:	P.O. BOX 1407
Address 2:
City:	PORTSMOUTH
State:	OH
Zip:	45662
Phone:	740-353-3121
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 1407
Address 2:
City:	PORTSMOUTH
State:	OH
Zip:	45662
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
CHARLES WILLIAM HERRMANN	AGENT	2516236	YES		01/01/2013

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:	CHARLES WILLIAM HERRMANN
Title:	AGENT
Phone Number:	740-353-4105 EXT. 127
Email Address:	CB@BERNDTMURFIN.COM