Notification of Changes for Business Entity
General Information
Business Entity Name:	WILSON INSURANCE SERVICES
Incorporation / Formation Date:
FEIN:	263884451
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	311 STONERIDGE LANE
Address 2:
City:	GAHANNA
State:	OH
Zip:	43230
Phone:	6145712815
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	311 STONERIDGE LANE
Address 2:
City:	GAHANNA
State:	OH
Zip:	43230
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
MEGAN WILSON	MANAGER	13808975	YES		03/01/2016ME

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:	MEGAN WILSON
Title:	ESTATE ADMIN WWA OF THOMAS C WILSON
Phone Number:	6143538000
Email Address:	MEGWILSON24@GMAIL.COM