Notification of Changes for Business Entity
General Information
Business Entity Name:	AG RM&I AGENCY, LLC
Incorporation / Formation Date:
FEIN:	45-3089931
Ohio License Number:	1110309
NPN:	16495056
DBA / Trade Name:
State of Domicile:	OK
County:	CADDO
Business Address
Address 1:	AG RM&I AGENCY, LLC
Address 2:	PO BOX 332
City:	APACHE
State:	OK
Zip:	73006
Phone:	580-588-5099
Fax:	580-588-9277
Business Web Site Address:
Business Email Address:	TERMAN@PLDI.NET
Mailing Address
Address 1:	PO BOX 332
Address 2:
City:	APACHE
State:	OK
Zip:	73006
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
JAMES DAKOTA MOSS	RDA	16739275	YES		3-20-2017

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)	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:	THERESA ERMAN
Title:	CSR
Phone Number:	5280-588-5099
Email Address:	TERMAN@PLDI.NET