Notification of Changes for Business Entity
General Information
Business Entity Name:	RUDOLPH INSURANCE AGENCY LLC
Incorporation / Formation Date:
FEIN:	050572944
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	LUCAS
Business Address
Address 1:	6588 SECOR ROAD #8
Address 2:
City:	LAMBERTVILLE
State:	MI
Zip:	48144
Phone:	734-206-1882
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	6588 SECOR ROAD #8
Address 2:
City:	LAMBERTVILLE
State:	MI
Zip:	48144
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DIANNE CHRISTINE RUDOLPH	OWNER	13065591	YES		08/28/2017

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:	DIANNE CHRISTINE RUDOLPH
Title:	OWNER
Phone Number:	734-206-1882
Email Address:	RIS@BEX.NET