Notification of Changes for Business Entity
General Information  
Business Entity Name: HAGERTY INSURANCE AGENCY LLC
Incorporation / Formation Date: 01/01/2010
FEIN: 880268247
Ohio License Number: 24109
NPN: 686949
DBA / Trade Name:  
State of Domicile: MI
County: USA
Business Address  
Address 1: 141 RIVERS EDGE DR, STE 200
Address 2:  
City: TRAVERSE CITY
State: MI
Zip: 49684
Phone: 2319417477
Fax:  
Business Web Site Address:  
Business Email Address: BBROOKS@HAGERTY.COM
Mailing Address  
Address 1: PO BOX 87
Address 2:  
City: TRAVERSE CITY
State: MI
Zip: 49685
   
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
SHANNA BRYANT AGENT 17837922 YES   02/19/2016
GRETCHEN NOVOROLSKY AGENT 17792862 YES   02/19/2016
SUSAN SIEGRIST-SWANSON AGENT 9074666   YES 02/19/2016
EMILY HUBBELL AGENT 17243943   YES 02/19/2016
SCOTT ADAMS AGENT 16547058   YES 02/19/2016
BRYSON WILBERT AGENT 16100892   YES 02/19/2016
ALEXANDER FAVREAU AGENT 17366517   YES 02/19/2016
NICOLE WITER AGENT 17090349   YES 02/19/2016
BROOKE LUALLIN AGENT 17707572   YES 02/19/2016
           
Members, Owners, Partners, Officers and Directors
Name Title Identifying # Add Delete Eff. Date
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: BETH BROOKS WEST
Title: SR LIC ADMIN
Phone Number: 2319326827
Email Address: BBROOKS@HAGERTY.COM