Notification of Changes for Business Entity
General Information
Business Entity Name:	SCHERER MOUNTAIN INSURANCE LLC
Incorporation / Formation Date:
FEIN:	26-1760021
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	LAWRENCE
Business Address
Address 1:	209 S 3RD STREET
Address 2:
City:	IRONTON
State:	OH
Zip:	45638
Phone:	740-532-8755
Fax:	740-532-2260
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P O BOX 664
Address 2:
City:	IRONTON
State:	OH
Zip:	45638
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
JARED S. GANDEE	CSR	17052134	YES		11/17/2017

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)
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:	JUELDA J COLLIS
Title:	OFFICE MANAGER
Phone Number:	740-532-8755
Email Address:	JCOLLINS@SCHERERMOUNTQAIN.COM