Notification of Changes for Business Entity
General Information
Business Entity Name:	A-G ADMINISTRATORS LLC
Incorporation / Formation Date:
FEIN:	23-2257310
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	860 FIRST AVENUE, SUITE 2
Address 2:
City:	KING OF PRUSSIA
State:	PA
Zip:	19406
Phone:	6109330800
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 979
Address 2:
City:	VALLEY FORGE
State:	PA
Zip:	19482
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	A-G ADMINISTRATORS INC
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	ALYSSA DOHERTY
Title:	AUTHORIZED SUBMITTER CSC
Phone Number:	8009279801
Email Address:	BLINSURANCE@CSCGLOBAL.COM