Notification of Changes for Business Entity
General Information
Business Entity Name:	FIRST INSURANCE GROUP OF THE MIDWEST, INC
Incorporation / Formation Date:
FEIN:	34-0940616
Ohio License Number:	1371
NPN:	2827188
DBA / Trade Name:
State of Domicile:	OH
County:	DEFIANCE
Business Address
Address 1:	511 FIFTH ST
Address 2:
City:	DEFIANCE
State:	OH
Zip:	43512
Phone:	419-784-5431
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 700
Address 2:
City:	DEFIANCE
State:	OH
Zip:	43512
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 SHARPE	ACCOUNT MANAGER	1883002	YES		8/20/2018

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:	CHAD RITTER
Title:	LICENSING
Phone Number:	419-784-5431
Email Address:	CRITTER@FIRSTINSURANCEGRP.COM