Notification of Changes for Business Entity
General Information
Business Entity Name:	WINGFIELD CROP INSURANCE SERVICE LLC
Incorporation / Formation Date:
FEIN:	201308137
Ohio License Number:	32505
NPN:	8386235
DBA / Trade Name:
State of Domicile:	OH
County:	HARDIN
Business Address
Address 1:	15230 STATE ROUTE 309
Address 2:
City:	KENTON
State:	OH
Zip:	43326
Phone:	4196750008
Fax:
Business Web Site Address:
Business Email Address:	INSURE@WINGFIELDCROP.COM
Mailing Address
Address 1:	15230 STATE ROUTE
Address 2:
City:	KENTON
State:	OH
Zip:	43326
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	REBECCA BROWNING
Title:	OWNER/AGENT
Phone Number:	4196750008
Email Address:	INSURE@WINGFIELDCROP.COM