Notification of Changes for Business Entity
General Information
Business Entity Name:	LOGAN INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	314445058
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	HOCKING
Business Address
Address 1:	53 S MARKET ST
Address 2:
City:	LOGAN
State:	OH
Zip:	43138
Phone:	7403858575
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	53 S MARKET ST
Address 2:
City:	LOGAN
State:	OH
Zip:	43138
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
ALEXANDER T ROSE	AGENT	18451484	YES		06/27/17

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?
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:	HOLLIE WALLACE
Title:	BOOKKEEPING
Phone Number:	7403858575
Email Address:	HOLLIE@LOGANINSURANCE.COM