Notification of Changes for Business Entity
General Information
Business Entity Name:	CENTRAL INSUREX AGENCY INC
Incorporation / Formation Date:
FEIN:	34-1266123
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	VAN WERT
Business Address
Address 1:	800 S WASHINGTON ST
Address 2:
City:	VAN WERT
State:	OH
Zip:	45891
Phone:	419-238-5551
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	800 S WASHINGTON ST
Address 2:
City:	VAN WERT
State:	OH
Zip:	45891
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
JASON BROWN	VICE PRESIDENT	7897857		YES	09-27-2017

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:	KARI SMITH
Title:	LICENSING ADMIN.
Phone Number:	812-886-0191
Email Address:	KNSMITH@SUPPORTIVEIS.COM