Notification of Changes for Business Entity
General Information
Business Entity Name:	IVERY & ASSOCIATES
Incorporation / Formation Date:	03/31/2016
FEIN:	812040125
Ohio License Number:	1102905
NPN:	17886577
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	714 WORTHINGTON WOODS BLVD
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43085
Phone:	5132549777
Fax:
Business Web Site Address:
Business Email Address:	SKIPIVERY@ALLSTATE.COM
Mailing Address
Address 1:	714 WORTHINGTON WOODS BLVD
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43085
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)	NO
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	I WAS A MANAGER AT STANLEY STEEMER CARPET CLEANING

Submitted By
Submitted By:	HAROLD E IVERY JR
Title:	PRESIDENT, SOLE OWNER
Phone Number:	5132549777
Email Address:	SKIPIVERY@ALLSTATE.COM