Notification of Changes for Business Entity
General Information
Business Entity Name:	AMICA GENERAL AGENCY
Incorporation / Formation Date:
FEIN:	05-0430401
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	RI
County:	PROVIDENCE
Business Address
Address 1:	100 AMICA WAY
Address 2:
City:	LINCOLN
State:	RI
Zip:	02865
Phone:	800-234-5433
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 6008
Address 2:
City:	PROVIDENCE
State:	RI
Zip:	02840
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
DONALD LEMAY	ASST. LIFE SALES SUPERVISOR	5441594		YES	11/20/15

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:	LOUIS F. MAZZA, JR., CLU, CHFC
Title:	SENIOR ASSISTANT VICE PRESIDENT
Phone Number:	800-234-5433
Email Address:	LMAZZA@AMICA.COM