Notification of Changes for Business Entity
General Information
Business Entity Name:	NEWMARKETS INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	51-0391861
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	PHIADELPHIA
Business Address
Address 1:	1 BEAVER VALLEY ROAD
Address 2:
City:	WILMIGNTON
State:	DE
Zip:	19803
Phone:	215-640-2590
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	436 WALNUT ST
Address 2:
City:	PHILADELPHIA
State:	PA
Zip:	19106
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
JULIA SANDERS	EMPLOYEE	10923576		YES	07-31-2017

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
JULIA SANDERS	EMPLOYEE	10923576		YES	07-31-2017

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:	KARI SMITH
Title:	LICENSING ADMIN
Phone Number:	812-886-0191
Email Address:	KNSMITH@SUPPORTIVEIS.COM