Notification of Changes for Business Entity
General Information
Business Entity Name:	ALLIED INSURANCE MANAGERS INC
Incorporation / Formation Date:
FEIN:	382751873
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	MACOMB
Business Address
Address 1:	1055 SOUTH BLVD EAST
Address 2:	SUITE 110
City:	ROCHESTER HILLS
State:	MI
Zip:	48307
Phone:	248-853-0930
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1055 SOUTH BLVD EAST
Address 2:	SUITE 110
City:	ROCHESTER HILLS
State:	MI
Zip:	48307
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
JAYSON BASS	VICE PRESIDENT	1421187	YES		03/07/2017

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:	CINDY SCHMIDT
Title:	TECHNICAL ASSISTANT
Phone Number:	248-853-0930
Email Address:	CSCHMIDT@ALLIEDINSMGR.COM