Notification of Changes for Business Entity
General Information
Business Entity Name:	KRAFT LAKE INS AGENCY INC
Incorporation / Formation Date:
FEIN:	38-2336672
Ohio License Number:
NPN:	65439
DBA / Trade Name:
State of Domicile:	MI
County:	KENT
Business Address
Address 1:	5600 BEECHTREE LANE SE
Address 2:
City:	CALEDONIA
State:	MI
Zip:	49316
Phone:	616-956-4121
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 2450
Address 2:
City:	GRAND RAPIDS
State:	MI
Zip:	49501
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
LETA LAUREN BAKER	EMPLOYEE	11518949		YES	12/10/2015
NICHOLAS RAY HOPKINS	AGENT	16009932		YES	12/10/2015
LYNN MCDANIEL	EMPLOYEE	986612		YES	12/10/2015

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:	KELLY PERRY
Title:	MARKETING SPECIALIST/LICENSING COORDINATOR FOR KRAFT LAKE
Phone Number:	913-564-6406
Email Address:	KELLY.PERRY@FARMERSINSURANCE.COM