Notification of Changes for Business Entity
General Information
Business Entity Name:	HUMPHREY INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	340834435
Ohio License Number:
NPN:	2773695
DBA / Trade Name:
State of Domicile:	OH
County:	ASHTABULA
Business Address
Address 1:	1258 WEST PROSPECT
Address 2:
City:	ASHTABULA
State:	OH
Zip:	44004
Phone:	440-998-1112
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1258 W PROSPECT
Address 2:
City:	ASHTABULA
State:	OH
Zip:	44004
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
DESIREE PHILLIPS	CSR	1155776	YES		07-27-2017

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)	YES
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	SALES CLERK RETAIL PAINT

Submitted By
Submitted By:	PETE STEVENSON
Title:	VICE PRESIDENT
Phone Number:	440-998-1112
Email Address:	PETE@HUMPHREYINSURANCEAGENCY.COM