Notification of Changes for Business Entity
General Information
Business Entity Name:	CHARLES J. MILLER INS. AGCY., INC.
Incorporation / Formation Date:
FEIN:	31-1332716
Ohio License Number:	685
NPN:	2776312
DBA / Trade Name:
State of Domicile:	OH
County:	CLERMONT
Business Address
Address 1:	191 E MAIN STREET
Address 2:
City:	BATAVIA
State:	OH
Zip:	45103
Phone:	513-732-1600
Fax:	513-732-5092
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	191 E MAIN STREET
Address 2:
City:	BATAVIA
State:	OH
Zip:	45103
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
CHASE E MILLER	AGENT	16089675	YES		11/01/2016

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:	CHARLES E MILLER
Title:	VP
Phone Number:	513-732-1600
Email Address:	MAKEBOND@AOL.COM