Notification of Changes for Business Entity
General Information
Business Entity Name:	BROOKS INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	344194540
Ohio License Number:	923
NPN:	957715
DBA / Trade Name:
State of Domicile:	OH
County:	LUCAS
Business Address
Address 1:	1120 MADISON AVE.
Address 2:
City:	TOLEDO
State:	OH
Zip:	43604
Phone:	419-243-1191
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1120 MADISON AVE.
Address 2:
City:	TOLEDO
State:	OH
Zip:	43604
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
ROSE ANN KOPERSKI	MARKETER	2441332		YES	03/11/2015
MICHELLE PHILLIPS	CLAIMS MANAGER	17019260		YES	03/11/2015
MELISSA SAYERS	BUSINESS DEVELOPMENT SPEC.	10427024		YES	03/11/2015

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:	AMY FORDE
Title:	EXECUTIVE ASSISTANT
Phone Number:	419-243-1191
Email Address:	AFORDE@BROOKSINSURANCE.COM