Notification of Changes for Business Entity
General Information
Business Entity Name:	PROVIDENCE GROUP OF OHIO CORPORATION (THE)
Incorporation / Formation Date:
FEIN:	541607105
Ohio License Number:	30138
NPN:	3005351
DBA / Trade Name:
State of Domicile:	VA
County:	CHESTERFIELD
Business Address
Address 1:	14410 SOMMERVILLE COURT SUITE 100
Address 2:
City:	MIDLOTHIAN
State:	VA
Zip:	23113
Phone:	8047940810
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	14410 SOMMERVILLE COURT SUITE 100
Address 2:
City:	MIDLOTHIAN
State:	VA
Zip:	23113
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
WILLIAM C STOECKELER	RDA	3521123	YES		9/14/2016
EUGENE MORRIS FINE	AGENT	7552820	YES		9/14/2016
JOSHUA DAVID VIVIAN	MANAGER	16852283		YES	9/14/2016
KEVIN BRENT NEWMAN	RDA	3080400		YES	9/14/2016
KEVIN BRENT NEWMAN	AGENT	3080400		YES	9/14/2016
KEVIN BRENT NEWMAN	PRESIDENT	3080400		YES	9/14/2016

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:	WILLIAM C STOECKELER
Title:	PRESIDENT
Phone Number:	(804) 794-0810
Email Address:	WSTOECKELER@THEPROVIDENCEGRP.COM