Notification of Changes for Business Entity
General Information
Business Entity Name:	A A HAMMERSMITH INSURANCE, INC.
Incorporation / Formation Date:
FEIN:	34-10080-99
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	STARK
Business Address
Address 1:	210 N ERIE ST
Address 2:
City:	MASSILLON
State:	OH
Zip:	44646-8450
Phone:	330-832-7411
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 591
Address 2:
City:	MASSILLON
State:	OH
Zip:	44648-0591
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
BONNIE J KINGSLEY	EMPLOYEE	2515783		YES	1/1/2017
WILLIAM R KRING	AGENT	1862269		YES	1/1/2017
DAVID L KUNTZMAN	EMPLOYEE	2346602		YES	1/1/2017
FRANCES C SHUFELT	AGENT	1782153		YES	1/1/2017
POLLY OFFENBECHER	AGENT	2341536		YES	1/1/2017
RAYMOND W JENSEN	AGENT	1029314		YES	1/1/2017
ROBBIE C HANSBARGER	AGENT	1862269		YES	1/1/2017
ROBBIE C HANSBARGER	EMPLOYEE	1862269		YES	1/1/2017

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
CHARLES L CLARK	VICE PRESIDENT	814927		YES	1/1/2017
CHARLES L CLARK	VICE PRESIDENT	814927		YES	1/1/2017
JAMES E CROOKSHANK	SECRETARY	509716		YES	1/1/2017
JOHN MULHBACH	VICE PRESIDENT	368654		YES	1/1/2017
JOHN MUHLBACH	VICE PRESIDENT	368654		YES	1/1/2017
PAUL MONTAGNO	PRESIDENT	2346574		YES	1/1/2017
PAUL MONTAGNO	RDA	2346574		YES	1/1/2017
WILLIAM S MCCALLUM	VICE PRESIDENT	1812143		YES	1/1/2017
ROBERT A MEADOWS	TREASURER	2424824	YES		4/1/2008
DOUGLAS H WEATHERBEE	PRESIDENT	2762371	YES		1/24/2007

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 A MEADOWS
Title:	TREASURER
Phone Number:	330-823-2283
Email Address:	RMEADOWS@AAHAMMERSMITH.COM