Notification of Changes for Business Entity
General Information
Business Entity Name:	DVM INSURANCE AGENCY
Incorporation / Formation Date:	05-30-2006
FEIN:	330096671
Ohio License Number:	34564
NPN:	16423
DBA / Trade Name:
State of Domicile:	CA
County:	ORANGE
Business Address
Address 1:	1800 E. IMPERIAL HWY #145
Address 2:
City:	BREA
State:	CA
Zip:	92821
Phone:	7149890555
Fax:
Business Web Site Address:
Business Email Address:	LICENSING@PETINSURANCE.COM
Mailing Address
Address 1:	PO BOX 2488
Address 2:
City:	BREA
State:	CA
Zip:	92822
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
JULIANA WOHLFEIL	AGENT	16767693		YES	11/02/2015

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:	CATHY SANTAMARIA
Title:	ANALYST
Phone Number:	7149890555
Email Address:	LICENSING@PETINSURANCE.COM