Notification of Changes for Business Entity
General Information
Business Entity Name:	HILL & HAMILTON INSURANCE AND FINANCIAL SERVICES
Incorporation / Formation Date:
FEIN:	34-1339727
Ohio License Number:	812500
NPN:	15728640
DBA / Trade Name:
State of Domicile:	OH
County:	LOGAN
Business Address
Address 1:	200 DOWELL AVENUE
Address 2:
City:	BELLEFONTAINE
State:	OH
Zip:	43311
Phone:	937-592-9076
Fax:	937-599-2568
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	200 DOWELL AVENUE
Address 2:
City:	BELLEFONTAINE
State:	OH
Zip:	43311
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	LIBERTY NATIONAL BANK
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
JILL ALLISON RAWLINS	CUSTOMER SERVICE REP	15728640	YES		02/09/2016

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:	JILL ALLISON RAWLINS
Title:	CUSTOMER SERVICE REP
Phone Number:	937-592-9076
Email Address:	JRAWLINS@HILLANDHAMILTON.COM