Notification of Changes for Business Entity
General Information
Business Entity Name:	BUSINES ENTITY NAME
Incorporation / Formation Date:
FEIN:	12
Ohio License Number:	12
NPN:	1
DBA / Trade Name:	1
State of Domicile:	OH
County:	FRANKLIN
Business Address
Address 1:	50 W. TOWN STREET
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43221
Phone:	6144567896
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	SYLVIA.KNOX@INSURANCE.OHIO.GOV
Address 2:
City:	COLUMBUS
State:	OH
Zip:	43221
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	OLD BUSINESS 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
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