Notification of Changes for Business Entity
General Information
Business Entity Name:	BERT CO
Incorporation / Formation Date:
FEIN:	251753349
Ohio License Number:	35984
NPN:	2009041
DBA / Trade Name:
State of Domicile:	PA
County:	ERIE
Business Address
Address 1:	800 STATE STREET STE 500
Address 2:
City:	ERIE
State:	PA
Zip:	16501
Phone:	8148380000
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	800 STATE STREET STE 500
Address 2:
City:	ERIE
State:	PA
Zip:	16501
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
MATTHEW TURK	COMMERCIAL LINES SUPERVISOR	2051318		YES	7/30/2018
CHRISTOPHER ALLEN	SVP	1725547	YES		7/30/2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
GREGORY LAROCCA	N/A	N/A		YES	7/30/2018

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)	NO
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:	ALYSSA ANDERSON
Title:	FINANCIAL SPECIALIST
Phone Number:	716-487-4763
Email Address:	ALYSSA.ANDERSON@NORTHWEST.COM