Notification of Changes for Business Entity
General Information
Business Entity Name:	GEICO INSURANCE AGENCY, INC
Incorporation / Formation Date:	11/06/1979
FEIN:	521168724
Ohio License Number:	27225
NPN:
DBA / Trade Name:
State of Domicile:	MD
County:	MONTGOMERY
Business Address
Address 1:	5260 WESTERN AVENUE
Address 2:
City:	CHEVY CHASE
State:	MD
Zip:	20815
Phone:	5402867132
Fax:	8773031105
Business Web Site Address:
Business Email Address:	TSAMUELS@GEICO.COM
Mailing Address
Address 1:	ONE GEICO BLVD
Address 2:
City:	FREDERICKSBURG
State:	VA
Zip:	22412
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
MATTHEW DELARUELLE	PRODUCER	18055523	YES		08-23-2016
CHELSEA DALE	PRODUCER	18055508	YES		08-23-2016

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:	KIMBERLY S LINDSAY
Title:	RDA
Phone Number:	540-286-7147
Email Address:	KLINDSAY@GEICO.COM