Notification of Changes for Business Entity
General Information
Business Entity Name:	PEDERSEN, DOWIE, CLABBY & MCCAUSLAND INSURANCE INC
Incorporation / Formation Date:
FEIN:	421362866
Ohio License Number:	30353
NPN:	2109374
DBA / Trade Name:
State of Domicile:	IA
County:	BLACK HAWK
Business Address
Address 1:	.3022 AIRPORT BLVD
Address 2:
City:	WATERLOO
State:	IA
Zip:	50703
Phone:	319-234-8888
Fax:	319-234-8888
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 2597
Address 2:
City:	WATERLOO
State:	IA
Zip:	50704
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	CHRIS UHLAND
Title:	AGENCY ASSISTANT
Phone Number:	319-296-7614
Email Address:	CUHLAND@PDCM.COM