Notification of Changes for Business Entity
General Information
Business Entity Name:	SPC INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	411888760
Ohio License Number:
NPN:	3202300
DBA / Trade Name:
State of Domicile:	MN
County:	RAMSEY COUNTY
Business Address
Address 1:	385 WASHINGTON STREET
Address 2:
City:	ST. PAUL
State:	MN
Zip:	55102
Phone:	8602771280
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	385 WASHINGTON STREET
Address 2:
City:	ST. PAUL
State:	MN
Zip:	55102
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
SUSAN MARIE GOETZ BERTRAM	VICE PRESIDENT, DIRECTOR, RDA	558799		YES	1/18/2018

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?	NO
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:	KELLY CONRAD
Title:	PARALEGAL
Phone Number:	8602771280
Email Address:	KCONRAD2@TRAVELERS.COM