Notification of Changes for Business Entity
General Information
Business Entity Name:	LOVELESS INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	41-2139311
Ohio License Number:	31513
NPN:	8175763
DBA / Trade Name:
State of Domicile:	OH
County:	FAIRFIELD
Business Address
Address 1:	7245 BABBERT PLACE SUITE A
Address 2:
City:	CANAL WINCHESTER
State:	OH
Zip:	43110
Phone:	6148370555
Fax:	6148341130
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	7245 BABBERT PLACE SUITE A
Address 2:
City:	CANAL WINCHESTER
State:	OH
Zip:	43110
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
ZACHERY LOVELESS	AGENT	16199332	YES		11/01/2017

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:	RANDALL LOVELESS
Title:	PRESIDENT
Phone Number:	6148370555
Email Address:	RANDY@LOVELESSINSURANCE.COM