Notification of Changes for Business Entity
General Information
Business Entity Name:	JACOBS INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	27-3785543
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	PICKAWAY
Business Address
Address 1:	128 WATT STREET
Address 2:
City:	CIRCLEVILLE
State:	OH
Zip:	43113
Phone:	740-474-1400
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	128 WATT STREET
Address 2:
City:	CIRCLEVILLE
State:	OH
Zip:	43113
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
BRADLEY JACOBS	PRINCIPAL	2779852	YES		01/01/2017
CHERYL FASKE	LICENSED PRODUCER	8877639	YES		01/01/2017
DEREK JACOBS	LICENSED PRODUCER	16550699	YES		01/01/2017

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:	BRADLEY JACOBS
Title:	PRINCIPAL
Phone Number:	740-474-1400
Email Address:	BRAD.JACOBSINS@GMAIL.COM