Notification of Changes for Business Entity
General Information
Business Entity Name:	COBOS INSURANCE CENTER
Incorporation / Formation Date:	04/01/2003
FEIN:	14-1871552
Ohio License Number:	2910
NPN:	7646394
DBA / Trade Name:
State of Domicile:	OH
County:	OH
Business Address
Address 1:	41436 GRISWOLD ROAD
Address 2:
City:	ELYRIA
State:	OH
Zip:	44035
Phone:	4403243732
Fax:	4403242584
Business Web Site Address:	WWW.COBOSINSURANCE.NET
Business Email Address:	QUALITY@COBOSINSURANCE.NET
Mailing Address
Address 1:	41436 GRISWOLD ROAD
Address 2:
City:	ELYRIA
State:	OH
Zip:	44035
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	BOB ALLEN INS AGENCY INC
New DBA/Trade Name:	YES	New DBA/Trade Name:	COBOS INSURANCE CENTER, INC.
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
MARY ELLEN ALLEN	AGENT	185270	YES		09/01/2017
LAURA LEE BLACKFORD	AGENT	3236701	YES		09/01/2017
CHARLES A MORGAN	AGENT	175175	YES		09/01/2017
TODD A KAUFFMAN	AGENT	17296103	YES		09/01/2017
CHIRSTINA MARIE BERNARD	AGENT	8633673	YES		09/01/2017
CAITLYN M BAIRD	AGENT	8863448	YES		09/01/2017
JOHN F COBOS	AGENT	17333441	YES		09/01/2017
CELESTE M WARD	AGENT	8854775	YES		09/01/2017
CARRIE L DECOST	AGENT	17336550	YES		09/01/2017
GARY YONTZ	AGENT	1499804	YES		09/01/2017
MACARIO COBOS	AGENT	1886126	YES		09/01/2017

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
ROBERTO F COBOS	PRESIDENT/AGENT	2775640	YES		09/01/2017

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:	DEBORAH A FISCHER
Title:	CONTROLLER
Phone Number:	4403243732
Email Address:	DEBBIE@COBOSINSURANCE.NET