Notification of Changes for Business Entity
General Information
Business Entity Name:	RURAL COMMUNITY INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	41-1708414
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	USA
Business Address
Address 1:	3501 THURSTON AVE.
Address 2:
City:	ANOKA
State:	MN
Zip:	55303
Phone:	763-323-2118
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	3501 THURSTON AVE.
Address 2:
City:	ANOKA
State:	MN
Zip:	55303
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
MARY MERKEL	DIRECTOR & EXEC VP	NONE		YES	07/08/2016
EUGENO FERNANDEZ	DIRECTOR & EXEC VP	NONE	YES		07/08/2016

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:	DEBORAH LARSON
Title:	ASST SECRETARY & VICE PRESIDENT
Phone Number:	763-323-2118
Email Address:	DEB.LARSON@RCIS.COM