Notification of Changes for Business Entity
General Information
Business Entity Name:	PMC ADVANTAGE INSURANCE SERVICES, INC.
Incorporation / Formation Date:
FEIN:	42-1155048
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	IA
County:	KOSSUTH
Business Address
Address 1:	808 HWY 18 W
Address 2:
City:	ALGONA
State:	IA
Zip:	50511
Phone:	515-295-2461
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 370
Address 2:
City:	ALGONA
State:	IA
Zip:	50511
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
BRADLEY J. FRIDERES	AGENT	17312432		YES	06/05/2017
SHIRLEY L FLICK	RDA	227984		YES	06/05/2017
SHIRLEY L. FLICK	OFFICER	227984		YES	06/05/2017

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:	KARLEEN WITTKOPF
Title:	LICENSING ASSOCIATE
Phone Number:	515-295-2461
Email Address:	KARLEEN.WITTKOPF@PHMIC.COM