Notification of Changes for Business Entity
General Information
Business Entity Name:	TYRICE WALKER INSURANCE AGENCY INC.
Incorporation / Formation Date:	01/08/2014
FEIN:	46-4011520
Ohio License Number:	1013939
NPN:	17143572
DBA / Trade Name:
State of Domicile:	OH
County:	BUTLER
Business Address
Address 1:	402 N 3RD STREET
Address 2:
City:	HAMILTON
State:	OH
Zip:	45011
Phone:	5138878734
Fax:	5138870215
Business Web Site Address:
Business Email Address:	TYRICE.WALKER.MJ93@STATEFARM.COM
Mailing Address
Address 1:	402 N 3RD STREET
Address 2:
City:	HAMILTON
State:	OH
Zip:	45011
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	TYRICE WALKER
Title:	AGENCY OWNER
Phone Number:	5138878734
Email Address:	TYRICE.WALKER.MJ93@STATEFARM.COM