Notification of Changes for Business Entity
General Information
Business Entity Name:	CONCEPT 4 INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	34-1301889
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	SUMMIT
Business Address
Address 1:	125 WEST AVENUE
Address 2:	SUITE 103
City:	TALLMADGE
State:	OH
Zip:	44278
Phone:	3306302543
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	125 WEST AVENUE
Address 2:	SUITE 103
City:	TALLMADGE
State:	OH
Zip:	44278
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
BECKY WILSON	AGENT	15725811		YES	07/20/2017

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)
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:	GABRIELLE R. LAMBACHER
Title:	OFFICE MANAGER/CSR
Phone Number:	3306302543
Email Address:	GABRIELLE@CONCEPT4INS.COM