Notification of Changes for Business Entity
General Information
Business Entity Name:	GUARDIAN INSURANCE WHOLESALERS, INC.
Incorporation / Formation Date:
FEIN:	27-2823281
Ohio License Number:	1036405
NPN:	15814921
DBA / Trade Name:
State of Domicile:	KY
County:	GRAYSON
Business Address
Address 1:	216 W WHITE OAK ST
Address 2:
City:	LEITCHFIELD
State:	KY
Zip:	42754
Phone:	270-230-0340
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 119
Address 2:
City:	LEITCHFIELD
State:	KY
Zip:	42755
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
CARY ALEXANDER	PRODUCER	69227		YES	7/19/16
DAVID HUFF	OWNER	7194438	YES		7/19/16

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:	EMILY GOOTEE
Title:	OFFICE MANAGER
Phone Number:	270-230-0340
Email Address:	EMILYG@GUARDIAN-INS.COM