Notification of Changes for Business Entity
General Information
Business Entity Name:	PAIGE & BYRNES INSURANCE
Incorporation / Formation Date:	1921
FEIN:	341534658
Ohio License Number:	831
NPN:	687156
DBA / Trade Name:
State of Domicile:	OH
County:	TRUMBULL
Business Address
Address 1:	9400 E MARKET ST
Address 2:
City:	WARREN
State:	OH
Zip:	44484
Phone:	3303932587
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	9400 E MARKET ST
Address 2:
City:	WARREN
State:	OH
Zip:	44484
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	DIANE EAKIN
Title:	LICENSING CO-ORDINATOR
Phone Number:	330-393-2587
Email Address:	DEAKIN@PAIGEBYRNES.COM