Notification of Changes for Business Entity
General Information
Business Entity Name:	ROBBINS-MATHERLY-DILS AGENCY, INC.
Incorporation / Formation Date:	12/31/1954
FEIN:	35-0958400
Ohio License Number:	24264
NPN:
DBA / Trade Name:
State of Domicile:	IN
County:	WAYNE
Business Address
Address 1:	36 SOUTH 9TH ST.
Address 2:
City:	RICHMOND
State:	IN
Zip:	47374
Phone:	765-966-7531
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 1167
Address 2:
City:	RICHMOND
State:	IN
Zip:	47375
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
TARA PIATT	PRODUCER	17604759	YES		05/02/2017

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:	DEANNA STANLEY
Title:	PRESIDENT OF KLS
Phone Number:	214-855-0737
Email Address:	DSTANLEY@KENNEDYLICENSING.COM