Notification of Changes for Business Entity
General Information
Business Entity Name:	THE BUREN INSURANCE GROUP, INC
Incorporation / Formation Date:
FEIN:	34-1237066
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	ASHLAND
Business Address
Address 1:	1101 SUGARBUSH DRIVE
Address 2:
City:	ASHLAND
State:	OH
Zip:	44805
Phone:	4192818060
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1101 SUGARBUSH DRIVE
Address 2:
City:	ASHLAND
State:	OH
Zip:	44805
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
ANDREW FAULKNER HOY	EMPLOYEE	15258422		YES	04/18/2016
BRAD JOSEPH ASBURY	AGENT	9212647		YES	04/18/2016
BRETT WILSON ADAMS	AGENT	1499295		YES	04/18/2016
BRUCE W KRAMER	AGENT	2772716		YES	04/18/2016
CAROL A LOCKSTEDT	MANAGER	2827186		YES	04/18/2016
JOHN M LANE	AGENT	2770597		YES	04/18/2016
KAREN K GILKISON	AGENT	2510016		YES	04/18/2016
NATALIE KATHLEEN HILLMAN	AGENT	9602987		YES	04/18/2016
PATRICIA M GRUBE	AGENT	1746053		YES	04/18/2016
RAYMOND C SHAUM	AGENT	1847925		YES	04/18/2016
STEVEN DAVID WATSON	AGENT	2545875		YES	04/18/2016

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:	BECKY WOLLESON
Title:	INSURANCE OPERATIONS MANAGER
Phone Number:	4192818060
Email Address:	BECKY.WOLLESON@BURENINSURANCEGROUP.COM