Notification of Changes for Business Entity
General Information
Business Entity Name:	RAY INSURANCE AGENCY, INC.
Incorporation / Formation Date:	03/10/1980
FEIN:	310979334
Ohio License Number:	3660
NPN:	1874455
DBA / Trade Name:
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	1580 FISHINGER RD
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43221
Phone:	6144591122
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1580 FISHINGER RD
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43221
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
JOHN G CARNEY	PRODUCER	5971277	YES		11/01/2016

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:	DAVID RAY
Title:	TREASURER AND SECRETARY
Phone Number:	6142469252
Email Address:	DAVID@RAYINSURANCE.COM