Notification of Changes for Business Entity
General Information
Business Entity Name:	SAM ROBINSON INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	17139439
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	STARK
Business Address
Address 1:	300 WALNUT AVENUE
Address 2:
City:	CANTON
State:	OH
Zip:	44702
Phone:	330-488-0005
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	300 WALNUT AVENUE
Address 2:
City:	CANTON
State:	OH
Zip:	44702
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
CHARLES BRETT HART	OFFICER	8990804		YES	01/03/2017

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)
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:	CHARLES BRETT HART
Title:	OFFICER
Phone Number:	2162788275
Email Address:	CHARLIE.9754@GMAIL.COM