Notification of Changes for Business Entity
General Information  
Business Entity Name: CROGHAN INSURANCE AGENCY, LLC
Incorporation / Formation Date:  
FEIN: 32 0289174
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: OH
County: SANDUSKY
Business Address  
Address 1: 323 CROGHAN STREET
Address 2:  
City: FREMONT
State: OH
Zip: 43420
Phone: 419.355.2293
Fax:  
Business Web Site Address:  
Business Email Address:  
Mailing Address  
Address 1: 323 CROGHAN STREET
Address 2:  
City: FREMONT
State: OH
Zip: 43420
   
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
VALERIE REED AGENT   YES 4/1/2016
MICHAEL KELSO AGENT 275 60 2609 YES   4/1/2016
           
Members, Owners, Partners, Officers and Directors
Name Title Identifying # Add Delete Eff. Date
RICK ROBERTSON PRESIDENT/MANAGER 294 52 8321 YES   4/1/2016
KENDALL RIEMAN SEC/TREAS/MANAGER 381 96 6762 YES   4/1/2016
CROGHAN COLONIAL BANK OWNER 34 1415683 YES   4/1/2016
ROBERT L PALMER RDA 232 88 6791 YES   4/1/2016
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) YES
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? YES
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement BANKING
Submitted By  
Submitted By: KENDALL RIEMAN
Title: SEC/TREAS/MANAGER
Phone Number: 419 355 2222
Email Address: KRIEMAN@CROGHAN.COM