Notification of Changes for Business Entity
General Information
Business Entity Name:	LELAND SMITH INSURANCE SERVICES
Incorporation / Formation Date:
FEIN:	35-1620044
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	VAN WERT
Business Address
Address 1:	1175 WESTWOOD DR
Address 2:	SUITE 200
City:	VAN WERT
State:	OH
Zip:	45891
Phone:	4192387880
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1175 WESTWOOD DR
Address 2:	SUITE 200
City:	VAN WERT
State:	OH
Zip:	45891
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
KYLE STRAWN	AGENT	18083048	YES		09012016

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:	RANDY D. MYERS
Title:	PRESIDENT
Phone Number:	4192387880
Email Address:	RMYERS@LELANSMITH.COM