Notification of Changes for Business Entity
General Information
Business Entity Name:	AMTRUST AGRICULTURE INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	35-2459750
Ohio License Number:	1093919
NPN:	16848301
DBA / Trade Name:
State of Domicile:	OH
County:	SAN FRANCISCO
Business Address
Address 1:	201 THIRD STREET, SUITE 1100
Address 2:
City:	SAN FRANCISCO
State:	CA
Zip:	94103
Phone:	860-571-3104
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	201 THIRD STREET, SUITE 1100
Address 2:
City:	SAN FRANCISCO
State:	CA
Zip:	94103
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
DELYNN D. TRIVISON	RDA	494991	YES		01/10/2018
STUART D. HOLLANDER	RDA	3393774		YES	01/10/2018
JEFFREY C. HAMLIN	AGENT	966969		YES	01/10/2018
KEVIN A. TOSCHLOG	AGENT	967964		YES	01/10/2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
BARRY MOSES	VP, SECRETARY	299-50-5624	YES		01/10/2018
HARRY SCHLACHTER	TREASURER	074-50-6936	YES		01/10/2018
STUART D. HOLLANDER	VICE PRESIDENT	132-56-8251	YES		01/10/2018

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
Submitted By:	CATHY KIMMEY
Title:	LICENSING SPECIALIST
Phone Number:	972-788-6811
Email Address:	PRODUCER.LICENSING@AMTRUSTGROUP.COM