Notification of Changes for Business Entity
General Information
Business Entity Name:	BROOKS INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	344194540
Ohio License Number:	923
NPN:	957715
DBA / Trade Name:
State of Domicile:	OH
County:	LUCAS
Business Address
Address 1:	1120 MADISON AVE.
Address 2:
City:	TOLEDO
State:	OH
Zip:	43604
Phone:	4192431191
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1120 MADISON AVE.
Address 2:
City:	TOLEDO
State:	OH
Zip:	43604
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
KELLY STRAUB	CLIENT EXECUTIVE	2762372		YES	01/22/2016
PEGGY MOLL	ADMINISTRATIVE ASSISTANT	16943062		YES	01/22/2016
COURTNEY BOOS	ACCOUNT MANAGER	16990749		YES	01/22/2016
COURTNEY COAKLEY	ACCOUNT MANAGER	16990749	YES		01/22/2016

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:	AMY FORDE
Title:	EXECUTIVE ASSISTANT
Phone Number:	419-254-7318
Email Address:	AFORDE@BROOKSINSURANCE.COM