Notification of Changes for Business Entity
General Information
Business Entity Name:	DVM INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	33-0096671
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	ORANGE
Business Address
Address 1:	1800 E. IMPERIAL HIGHWAY, SUITE 145
Address 2:
City:	BREA
State:	CA
Zip:	92821
Phone:	5155084564
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1800 E. IMPERIAL HIGHWAY, SUITE 145
Address 2:
City:	BREA
State:	CA
Zip:	92821
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
MICHAEL COUTURE	DVM INSURANCE AGENCY	8884478	YES		10/21/2016
KENNETH ILES	DVM INSURANCE AGENCY	7446748	YES		10/21/2016
KEVIN BURTCH	DVM INSURANCE AGENCY	15343943	YES		10/21/2016
AMY BARTON	DVM INSURANCE AGENCY	767699	YES		10/21/2016
LISA WIDNER	DVM INSURANCE AGENCY	7663416	YES		10/21/2016
ELINOR FOURLICHT	DVM INSURANCE AGENCY	17186992	YES		10/21/2016
AMY BARTON	DVM INSURANCE AGENCY	6543479	YES		10/21/2016
OMAR OAZZA	DVM INSURANCE AGENCY	17476009	YES		10/21/2016
MARY SCHOENMAN	DVM INSURANCE AGENCY	17905281	YES		10/21/2016
NATALIE ANDERSON	DVM INSURANCE AGENCYDVM INSURA	17836872	YES		10/21/2016
LISA WIDNER	DVM INSURANCE AGENCY	1934352	YES		10/21/2016
JONATHAN SNELL	DVM INSURANCE AGENCY	8803111	YES		10/21/2016
CARTER HASAN	DVM INSURANCE AGENCY	16163437	YES		10/21/2016
DANIEL CABANA	DVM INSURANCE AGENCY	8769124	YES		10/21/2016
MARIA BOHANNER	DVM INSURANCE AGENCY	11604300	YES		10/21/2016

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:	SAMANTHA ZEPEDA
Title:	SR LICENSING TECH
Phone Number:	5155084564
Email Address:	NSSLICGL@NATIONWIDE.COM