Notification of Changes for Business Entity
General Information
Business Entity Name:	BILLING INS
Incorporation / Formation Date:	10/07/1991
FEIN:	31-1183459
Ohio License Number:
NPN:	2773648
DBA / Trade Name:
State of Domicile:	OH
County:	SHELBY
Business Address
Address 1:	313 W MAIN ST.
Address 2:
City:	ANNA
State:	OH
Zip:	45302
Phone:	9373942132
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 28
Address 2:
City:	ANNA
State:	OH
Zip:	45302
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
MATTHEW J ECHOLS	AGENT	17811582	YES		12/25/2015

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)	NO
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

Submitted By
Submitted By:	KEVIN BERNER
Title:	PRINCIPAL/OWNER
Phone Number:	9373942132
Email Address:	BILLINGINSURANCE@NKTELCO.NET