Notification of Changes for Business Entity
General Information
Business Entity Name:	FROST INSURANCVE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	31-1031530
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	HENRY
Business Address
Address 1:	120 RAILWAY AVE.
Address 2:
City:	HOLGATE
State:	OH
Zip:	43527
Phone:	419-264-2051
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 367
Address 2:
City:	HOLGATE
State:	OH
Zip:	43527
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
MAEGAN BROWN	CUSTOMER SERVICE REP	18293129	YES		01/25/2017

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:	JEFFREY S. BOULTON
Title:	PRESIDENT
Phone Number:	419-264-2051
Email Address:	JEFF@FROSTINS.COM