Notification of Changes for Business Entity
General Information
Business Entity Name:	CROGHAN INSURANCE AGENCY, LLC
Incorporation / Formation Date:
FEIN:	320289174
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	SANDUSKY
Business Address
Address 1:	323 CROGHAN STREET
Address 2:
City:	FREMONT
State:	OH
Zip:	43420
Phone:	419 355 2222
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	323 CROGHAN STREET
Address 2:	BOX C
City:	FREMONT
State:	OH
Zip:	OH
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
CRYSTAL L PETERSON	AGENT			YES	11/1/2016
DARLENE D TYLER	AGENT			YES	11/1/2016
JAMES SAROSY	RDA	286 62 2449	YES		11/1/2016

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)
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:	ROBERT PALMER
Title:	RDA
Phone Number:	614.846.2170
Email Address:	RLPALMER@CBAO.COM