Notification of Changes for Business Entity
General Information
Business Entity Name:	DIXIE LEAVITT AGENCY
Incorporation / Formation Date:
FEIN:	880085613
Ohio License Number:	960204
NPN:	2747599
DBA / Trade Name:
State of Domicile:	NV
County:	CLARK
Business Address
Address 1:	7881 W CHARLESTON BLVD STE 140
Address 2:
City:	LAS VEGAS
State:	NV
Zip:	89117
Phone:	7023824010
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	7881 W CHARLESTON BLVD STE 140
Address 2:
City:	LAS VEGAS
State:	NV
Zip:	89117
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
RODNEY B LEAVITT	RDA	1686702		YES	03/27/2018

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:	KATIE NEWGARD / LICENSING PROFESSIONALS
Title:	LICENSING SPECIALIST
Phone Number:	8885435432
Email Address:	KNEWGARD@LICENSINGPROS.COM