Notification of Changes for Business Entity
General Information
Business Entity Name:	CBAO INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	310935455
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	8800 LYRA DRIVE STE 570
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43240
Phone:	6148462238
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	8800 LYRA DRIVE STE 570
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43240
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
CBAO SERVICE CORPORATION	OWNER	310936372	YES		9/26/16

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:	JAMES SAROSY
Title:	RDA
Phone Number:	614 846 2170
Email Address:	JJSAROSY@CBAO.COM