Notification of Changes for Business Entity
General Information
Business Entity Name:	PHELAN INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	34-0900043
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	DARKE
Business Address
Address 1:	863 EAST MAIN STREET
Address 2:
City:	VERSAILLES
State:	OH
Zip:	45380
Phone:	937-526-3111
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	863 EAST MAIN STREET
Address 2:	PO BOX 1
City:	VERSAILLES
State:	OH
Zip:	45380
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
SHERRI MULLINS	MANAGER	18216333	YES		12/1/2016
SHARI ROGERS	MANAGER	16201330	YES		1/9/2017

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:	LINDSEY BURKE
Title:	ACCOUNTING ASSISTANT/LICENSING COORDINATOR
Phone Number:	937-526-3111
Email Address:	LINDSEY_BURKE@PHELANINS.COM