Notification of Changes for Business Entity
General Information
Business Entity Name:	KESNER INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	34-1255780
Ohio License Number:	2708
NPN:	2444799
DBA / Trade Name:
State of Domicile:	OH
County:	ALLEN
Business Address
Address 1:	1240 W MARKET ST
Address 2:
City:	LIMA
State:	OH
Zip:	45805
Phone:	419-229-1216
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1240 W MARKET ST
Address 2:
City:	LIMA
State:	OH
Zip:	45805
Indicate the type of change you are seeking
Address Change:	YES
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
MARK KESNER	AGENT	15734381	YES		09/06/2016
STACEE KALLA	AGENT	17966165	YES		09/06/2016
JO SCHICK	AGENT	1816198		YES	09/06/2016
VICKI HUGHES	AGENT	2755602		YES	09/06/2016

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:	JEROME KESNER
Title:	PRESIDENT
Phone Number:	419-229-1216
Email Address:	JKESNER@KES-INS.COM