Notification of Changes for Business Entity
General Information
Business Entity Name:	FIFTH THIRD INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	31-1282942
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	HAMILTON
Business Address
Address 1:	34 FOUNTAIN SQUARE PLAZA
Address 2:
City:	CINCINNATI
State:	OH
Zip:	45263
Phone:	513-534-7421
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	34 FOUNTAIN SQUARE PLAZA
Address 2:
City:	CINCINNATI
State:	OH
Zip:	45263
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
MICHAEL PRATT	INS. ADVISOR P & C	8403671	YES		11/12/2018
MICHAEL RADEMAKER	CLIENT MGMT SYSTEM	7068946	YES		11/12/2018
MARK ROBERTO	ACCOUNT EXECUTIVE	2095562	YES		11/12/2018
BUDDER SHUNNARAH	EMP. BENEFITS ACCT MGR	8351797	YES		11/12/2018
DANA SNIDER	INSURANCE PRODUCER	8657653	YES		11/12/2018
JOSEPH SORRELL	INS. ADVISOR P & C	3954664	YES		11/12/2018
ELIZABETH STANKO	P & C ACCT. MGR.	2765862	YES		11/12/2018
BRIAN TALBOT	INSURANCE OPERATIONS DIRECTOR	8513762	YES		11/12/2018
DONALD THOMPSON	MD, INS. AGENCY SERVICES	1999045	YES		11/12/2018
GRAHAM VOLLMER	INSURANCE PRODUCER	16209535	YES		11/12/2018
STACEY WOODRUM	ACCOUNT MANAGER	17532745	YES		11/12/2018

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:	JENNIFER BRINCK
Title:	ANNUITY PROCESSING SPECIALIST
Phone Number:	513-358-2891
Email Address:	JENNIFER.BRINCK@53.COM