Notification of Changes for Business Entity
General Information
Business Entity Name:	CLARK THEDERS INSURANCE AGENCY, INC.
Incorporation / Formation Date:	11/30/1992
FEIN:	31-1364318
Ohio License Number:	1262
NPN:
DBA / Trade Name:	RISKSOURCE CLARK-THEDERS
State of Domicile:	OH
County:	BUTLER
Business Address
Address 1:	9938 CRESCENT PARK DRIVE
Address 2:
City:	WEST CHESTER
State:	OH
Zip:	45069
Phone:	513-779-2800
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P. O. BOX 62386
Address 2:
City:	CINCINNATI
State:	OH
Zip:	45262
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
KASEY YOUNG	ACCOUNT EXECUTIVE	12719254	YES		11/27/15

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:	THERESA CLAYTON
Title:	DIRECTOR OF AGENCY OPERATIONS
Phone Number:	513-779-2800
Email Address:	TCLAYTON@RISKSOURCE.COM