Notification of Changes for Business Entity
General Information
Business Entity Name:	LAYNE FINANCIAL
Incorporation / Formation Date:	05/01/2016
FEIN:	204886688
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	PA
County:	LAWRENCE
Business Address
Address 1:	315 GREEN RIDGE ROAD
Address 2:	STE H-1
City:	NEW CASTLE
State:	PA
Zip:	16105
Phone:	7246573443
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	315 GREEN RIDGE ROAD
Address 2:	STE H-1
City:	NEW CASTLE
State:	PA
Zip:	16105
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
JEREMY LUTZ	BENEFIT SPECILIST	17493493	YES		12/20/2016

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:	CHERI COCHRAN
Title:	ADMINISTRATOR/CONTRACTING
Phone Number:	7246573443
Email Address:	CCOCHRAN@BOSTBENEFITS.COM