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  5. PAYNE INSURANCE AGENCY, INC.

PAYNE INSURANCE AGENCY, INC.

Company Details

Entity Name: PAYNE INSURANCE AGENCY, INC.
Jurisdiction: Illinois
Entity Type: Corporation - Domestic BCA
Status: Dissolved
Date Formed: 13 Jun 2000
Date of Dissolution: 27 Feb 2018
Company Number: CORP_61123806
File Number: 61123806
Type of Business: Insurance and/or real estate agencies and brokers
Date Status Change: 27 Feb 2018
Place of Formation: ILLINOIS

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
PAYNE INSURANCE AGENCY, INC. PROFIT-SHARING PLAN 2016 371399663 2017-08-31 PAYNE INSURANCE AGENCY, INC. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-07-01
Business code 524210
Sponsor’s telephone number 3093653231
Plan sponsor’s address 401 WEST MAIN STREET, LEXINGTON, IL, 61753

Signature of
Role Plan administrator
Date 2017-08-31
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
PAYNE INSURANCE AGENCY, INC. PROFIT-SHARING PLAN 2015 371399663 2016-10-13 PAYNE INSURANCE AGENCY, INC. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-07-01
Business code 524210
Sponsor’s telephone number 3093653231
Plan sponsor’s address 401 WEST MAIN STREET, LEXINGTON, IL, 61753

Signature of
Role Plan administrator
Date 2016-10-13
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2016-10-13
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
PAYNE INSURANCE AGENCY, INC. PROFIT-SHARING PLAN 2014 371399663 2015-07-15 PAYNE INSURANCE AGENCY, INC. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-07-01
Business code 524210
Sponsor’s telephone number 3093653231
Plan sponsor’s address 401 WEST MAIN STREET, LEXINGTON, IL, 61753

Signature of
Role Plan administrator
Date 2015-07-15
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2015-07-15
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
PAYNE INSURANCE AGENCY, INC. PROFIT-SHARING PLAN 2013 371399663 2014-06-11 PAYNE INSURANCE AGENCY, INC. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-07-01
Business code 524210
Sponsor’s telephone number 3093653231
Plan sponsor’s address 401 WEST MAIN STREET, LEXINGTON, IL, 61753

Signature of
Role Plan administrator
Date 2014-06-11
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2014-06-11
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
PAYNE INSURANCE AGENCY, INC. PROFIT-SHARING PLAN 2012 371399663 2014-06-11 PAYNE INSURANCE AGENCY, INC. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-07-01
Business code 524210
Sponsor’s telephone number 3093653231
Plan sponsor’s address 401 WEST MAIN STREET, LEXINGTON, IL, 61753

Signature of
Role Plan administrator
Date 2014-06-11
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2014-06-11
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
PAYNE INSURANCE AGENCY, INC. PROFIT-SHARING PLAN 2011 371399663 2014-06-11 PAYNE INSURANCE AGENCY, INC. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-07-01
Business code 524210
Sponsor’s telephone number 3093653231
Plan sponsor’s address 401 WEST MAIN STREET, LEXINGTON, IL, 61753

Plan administrator’s name and address
Administrator’s EIN 371399663
Plan administrator’s name PAYNE INSURANCE AGENCY, INC.
Plan administrator’s address 401 WEST MAIN STREET, LEXINGTON, IL, 61753
Administrator’s telephone number 3093653231

Signature of
Role Plan administrator
Date 2014-06-11
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2014-06-11
Name of individual signing RANDY D. JACOBS
Valid signature Filed with authorized/valid electronic signature

Agent

Name and Address Role Appointment Date
RANDY D JACOBS, 401 W MAIN ST, LEXINGTON, 61753, MC LEAN Agent 2012-11-08

President

Name and Address Role
RANDY D JACOBS, 401 W MAIN STLEXINGTON 61753 President

Shares

Class Series Voting Rights Authorized Shares Issued Shares Par Value
COMMON No data Voting Rights 1000 100000 No data

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 13 Jan 2025

Sources: Illinois Office of the Secretary of State

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