Notification of Changes for Business Entity
General Information
Business Entity Name:	BUSINES NAME
Incorporation / Formation Date:	02/02/2018
FEIN:	123
Ohio License Number:	1
NPN:	2
DBA / Trade Name:	DBA NAME
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	BA1
Address 2:	BA2
City:	COLUMBUS
State:	OH
Zip:	43221
Phone:	6147894569
Fax:	6427894569
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	50 W. TOWN STREET
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43221
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
A	B	C	YES		02/02/2018
D	E	F		YES	01/01/2018
G	H	I	YES		03/03/2018

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
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