Notification of Changes for Business Entity Form

Complete all required fields below. Toggle opening/closing each section by clicking the section name. Required fields are marked with a red *.

Click for Printable Version of this Form

Click for Instructions on Large Volume producer affiliation transactions

At the Ohio Department of Insurance, we are committed to providing Business Entities with the tools and resources to manage their licensing needs efficiently. As part of this commitment, we are enhancing our systems to introduce more self-service and automated features.

It is important to note that once our system enhancements take effect, any changes to a Business Entity’s profile, including the addition of Agents (Producers), will need to be completed by an individual affiliated with the business under one of the following designation types:

                    •	Officer
                    •	Manager
                    •	Member
                    •	Director
                    •	President
                    •	Owner
                    •	Partner
                    •	Treasurer
                    •	Vice President
                    •	RDA
                    •	Secretary
                    •	Licensing Coordinator
                

Ensuring these affiliations are accurate now will help avoid disruptions once the new system goes live.

PLEASE NOTE: If the individual completing this form is not listed as an affiliated individual with the Business Entity, they will not be able to proceed with entering changes in the future due to system upgrades. To ensure future access, please add the submitter as a licensing coordinator, or other appropriate affiliation type below, or have an affiliated user complete all future transactions.

Business Entity Name: *

Incorporation/Formation Date

FEIN: *

Ohio License Number:

NPN (National Producer Number):

DBA/Trade Name (if applicable):

State of Domicile: *

County:

Business Address 1: *

Business Address 2:

Business City: *

Business State: *

Business Zip: *

Business Phone: *

Fax:

Business Web Site:

Business Email: *

Mailing Address 1: *

Mailing Address 2:

Mailing City: *

Mailing State: *

Mailing Zip: *

Address Change

Business

Mailing

Phone Number Change

Email Address Change

Amend Business Entity Name

New Business Entity Name:

Add Alias/Trade Name

New Alias/Trade Name:

Remove Alias/Trade Name

Old Alias/Trade Name:

Add or Delete Producers, Members, Owners, Partners, Officers, Licensing Coordinator and/or Directors: As noted in the below section(s)

Name, Title, NPN, Add or Delete, and Eff. Date are required for each entry.

NPN=National Producer Number

Please click + Add/Remove an Individual on the grid below to Add/Remove an individual

Identify changes for members, owners, partners, officers, directors and licensing coordinators of business entity.

Name, Title, NPN, Add or Delete, and Eff. Date are required for each entry.

NPN=National Producer Number

Please click + Add/Remove an Individual on the grid below to Add/Remove an individual

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"

I certify that I am an officer, director, principal or partner of the business entity, member or manager of a limited liability company, or otherwise authorized to act on behalf of the entity; and that all of the information submitted in this application and attachments is true and complete. I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity to civil or criminal penalties.

Please Note:

Please contact the Department at 614-644-2665 for instructions for the following types of changes:

                                * Residency (Home State) change
                                * Tax ID number change
                                * Surrender of license
                                * Merger of business entities
                                * Affiliation changes of 50 or more licensed producers (instructions)
                                * Any other changes to Agency not listed on the form.
                            

Submitted By: *

Title: *

Phone: *

Email: *

Captcha: *

Change

(Uppercase Only)