Notification of Changes for Business Entity
General Information
Business Entity Name:	PARKER STEVENS AGENCY, LLC
Incorporation / Formation Date:
FEIN:	39-2041981
Ohio License Number:	28219
NPN:	7343748
DBA / Trade Name:
State of Domicile:	WI
County:	PORTAGE
Business Address
Address 1:	1800 NORTH POINT DR
Address 2:
City:	STEVENS POINT
State:	WI
Zip:	54481
Phone:	800-248-4087
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1800 NORTH POINT DR
Address 2:
City:	STEVENS POINT
State:	WI
Zip:	54481
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
PENNY JO MORDICA	DIRECT SALES REP	6733640	YES		08/30/18
DAKOTA M REGAN	DIRECT SALES REP	18468826	YES		08/30/18
PARKER J SEDLAK	DIRECT SALES REP	18506105	YES		08/30/18
ANDREW KRUGER SELBST	DIRECT SALES REP	17775266	YES		08/30/18
MARISA DAWN SIGMOND	DIRECT SALES REP	14763454	YES		08/30/18
RICARDO VARGAS	DIRECT SALES REP	18476460	YES		08/30/18
JAMES ALBERT WELLS	DIRECT SALES REP	3515158	YES		08/30/18
BERNADETTE P WYNNE	DIRECT SALES REP	18480036	YES		08/30/18
REYMUNDO FERNANDEZ	DIRECT SALES REP	18708012	YES		08/30/18
JAMIE SUE CYCHOSZ	DIRECT SALES SUPERVISOR	6538548	YES		08/30/18
MARGARET ALFORD	DIRECT SALES REP	3990071	YES		08/30/18
LINA M RODRIGUEZ MIRAZO	DIRECT SALES REP	18832663	YES		08/30/18
TRISHA L PANNKUK	DIRECT SALES REP	18810789	YES		08/30/18
JOLENE E RUNKLE	DIRECT SALES REP	18796512	YES		08/30/18
NATASHA PILAR BOUDY	DIRECT SALES REP	17324036	YES		08/30/18

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:	NANCY PETRUSKA
Title:	SUPPORT SUPERVISOR
Phone Number:	715-346-7383
Email Address:	NANCY.PETRUSKA@SENTRY.COM