Notification of Changes for Business Entity
General Information
Business Entity Name:	WEST & KNOX MUTUAL INSURANCE COMPANY
Incorporation / Formation Date:
FEIN:	34-0651779
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	CARROLL
Business Address
Address 1:	355 LEATHERBERRY RD
Address 2:
City:	CARROLLTON
State:	OH
Zip:	44615
Phone:	330-627-0230
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	355 LEATHERBERRY RD
Address 2:
City:	CARROLLTON
State:	OH
Zip:	44615
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
JANET ILENE RICER	AGENT	18820588	YES		6/23/2018
DENA M FIGLEY	AGENT	624669		YES	11-27-2017
JEANNIE MARIE KRIETZER	AGENT	1022465	YES		11-27-2017

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)	NO
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?	NO
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:	SUSAN L. BARBER
Title:	TREASURER
Phone Number:	330-627-0230
Email Address:	SBARBER@WESTANDKNOX.COM