Notification of Changes for Business Entity
General Information
Business Entity Name:	COOPER/TARVIN INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	311120562
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	CLERMONT
Business Address
Address 1:	1010 STATE ROUTE 125
Address 2:	SUITE A
City:	CINCINNATI
State:	OH
Zip:	45245
Phone:	5137529960
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1010 STATE ROUTE 125
Address 2:	SUITE A
City:	CINCINNATI
State:	OH
Zip:	45245
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
CATHERINE CAROLE NESTER	AGENT	16448182	YES		08/21/2018
SARAH E DICKSON	AGENT	18656934	YES		08/21/2018
HEARL D TACKETT	AGENT	16770944	YES		08/21/2018
CALEB JAMES TAYLOR	AGENT	18074807	YES		08/21/2018

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)	NO
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?	NO
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:	JEREL V OSBORNE
Title:	PRESIDENT
Phone Number:	5137529960
Email Address:	CTINSURANCE@FUSE.NET