Notification of Changes for Business Entity
General Information  
Business Entity Name: AUTOMOBILE CLUB INSURANCE AGENCY, INC
Incorporation / Formation Date:  
FEIN: 31-6032293
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: OH
County: FRANKLIN
Business Address  
Address 1: 90 E WILSON BRIDGE RD
Address 2:  
City: WORTHINGTON
State: OH
Zip: 43085
Phone: 614-431-7800
Fax:  
Business Web Site Address:  
Business Email Address:  
Mailing Address  
Address 1: 90 E WILSON BRIDGE RD
Address 2:  
City: WORTHINGTON
State: OH
Zip: 43085
   
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
JAKOB SCHURCH AGENT 12410374 YES   07/09/2018
STEPHEN REFFITT AGENT 16140042   YES 10/05/2018
NICHOLAS MURNANE AGENT 17512862 YES   9/27/2018
DUSTIN HENTHORNE AGENT 15755464   YES 08/29/2018
VICTOR WOLFE AGENT 514809 YES   11/05/2018
CHADWICK LAWSON AGENT 17511360   YES 11/14/2018
           
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) NO
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? NO
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: STEPHANIE SHEGITZ
Title: DIRECTOR, INSURANCE OPERATIONS
Phone Number: 614-431-7869
Email Address: INSLICENSING@AAAOHIO.COM