Notification of Changes for Business Entity
General Information
Business Entity Name:	GROSS INSURANCE AGENCY, LLC
Incorporation / Formation Date:	10/01/1972
FEIN:	202087623
Ohio License Number:	33140
NPN:	8345716
DBA / Trade Name:
State of Domicile:	KY
County:	CAMPBELL
Business Address
Address 1:	26 NORTH FORT THOMAS AVENUE
Address 2:
City:	FORT THOMAS
State:	KY
Zip:	41075
Phone:	859-781-0434
Fax:	859-781-1780
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 75249
Address 2:
City:	FORT THOMAS
State:	KY
Zip:	41075
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
NICHOLAS ROLF	AGENT	962243	YES		11/15/2016

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)
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:	PAULA ARTHUR
Title:	AGENT
Phone Number:	859-781-0434
Email Address:	PAULA.ARTHUR@GROSS-INS.COM