Notification of Changes for Business Entity
General Information
Business Entity Name:	EXPLORER RV INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	311548235
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	SUMMIT
Business Address
Address 1:	3250 INTERSTATE DRIVE
Address 2:
City:	RICHFIELD
State:	OH
Zip:	44286
Phone:	8887746778
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 568
Address 2:
City:	RICHFIELD
State:	OH
Zip:	44286
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
WILLIAM C TUTTLE	MANAGER	1767677		YES	2/17/2017
STACIE A. PRICE	AGENT	17102766		YES	2/17/2017

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:	ANTHONY J. MERCURIO
Title:	PRESIDENT
Phone Number:	3306598900
Email Address:	TONY.MERCURIO@NATL.COM