Notification of Changes for Business Entity
General Information
Business Entity Name:	X S BROKERS INSURANCE AGENCY, INC.
Incorporation / Formation Date:	12/05/1978
FEIN:	04-2658206
Ohio License Number:	942793V
NPN:	2330654
DBA / Trade Name:
State of Domicile:	MA
County:	US
Business Address
Address 1:	13 TEMPLE ST.
Address 2:
City:	QUINCY
State:	MA
Zip:	02169
Phone:	617-471-7171
Fax:	617-471-7180
Business Web Site Address:
Business Email Address:	GJACKMAN@XSBROKERS.COM
Mailing Address
Address 1:	13 TEMPLE ST.
Address 2:
City:	QUINCY
State:	MA
Zip:	02169
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
PATRICIA ROTH	PRODUCER	749444		YES	11/15/2016

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:	HAILEY OVERBY
Title:	TREAS OF KLS
Phone Number:	2148550737
Email Address:	HOVERBY@KENNEDYLICENSING.COM