Notification of Changes for Business Entity
General Information
Business Entity Name:	WICHERT INSURANCE SERVICES INC
Incorporation / Formation Date:	01/25/1971
FEIN:	341081978
Ohio License Number:	658
NPN:	2432894
DBA / Trade Name:
State of Domicile:	OH
County:	SUMMIT
Business Address
Address 1:	1200 GRAHAM ROAD
Address 2:
City:	CUYAHOGA FALLS
State:	OH
Zip:	44224
Phone:	330-929-8686
Fax:
Business Web Site Address:	WWW.WICHERT.COM
Business Email Address:
Mailing Address
Address 1:	1200 GRAHAM ROAD
Address 2:
City:	CUYAHOGA FALLS
State:	OH
Zip:	44224
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 TRACEY COMBS	EMPLOYEE	16905358	YES		08/25/2017
ERIC OSCAR PEMPUS	EMPLOYEE	8643649	YES		08/25/2017
TRACEY HEISE	AGENT	3236846	YES		08/25/2017
KELLIE SNYDER	AGENT	18478672	YES		08/25/2017
DEBI SMITH	AGENT	3237232	YES		08/25/2017
BETH GORDON	AGENT	11898877	YES		08/25/2017
MELISSA URIAN	AGENT	18453360	YES		08/25/2017
KAREN GARRISON	AGENT	4019096	YES		08/25/2017
BOB TOWNER	AGENT	2780975	YES		08/25/2017
CRYSTAL THOMPSON	AGENT	18493557	YES		08/25/2017
CHRIS SHOP	AGENT	2775712		YES	08/25/2017
JILL SUZANNE SWIMM	AGENT	16337766		YES	08/25/2017
SANDRA A HINTZ	AGENT	2334506		YES	08/25/2017

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)	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:	MARY MACKEY
Title:	ACCOUNTING MANAGER
Phone Number:	330-920-8629
Email Address:	MARY@WICHERT.COM