Notification of Changes for Business Entity
General Information
Business Entity Name:	PAROUBEK INSURANCE AGENCY INC
Incorporation / Formation Date:	9-12-1989
FEIN:	341617118
Ohio License Number:	5496
NPN:	1703304
DBA / Trade Name:
State of Domicile:	OH
County:	LAKE
Business Address
Address 1:	7923 MUNSON RD STE 2
Address 2:
City:	MENTOR
State:	OH
Zip:	44060
Phone:	440-257-1804
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	7923 MUNSON RD STE 2
Address 2:
City:	MENTOR
State:	OH
Zip:	44060
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
SCOTT LOHREY	AGENT	16581413		YES	12-19-2016
TRACY PAROUBEK	AGENT	17302407	YES		12-19-2016

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:	JON PAROUBEK
Title:	OWNER
Phone Number:	440-257-1804
Email Address:	JPAROUBEK@SBCGLOBAL.NET