Notification of Changes for Business Entity
General Information
Business Entity Name:	MOUNTAIN WEST AGENCY SERVICES INC
Incorporation / Formation Date:
FEIN:	262934226
Ohio License Number:	11518547
NPN:
DBA / Trade Name:
State of Domicile:	AZ
County:	MARCICOPA
Business Address
Address 1:	3030 N 3RD ST
Address 2:
City:	PHOENIX
State:	AZ
Zip:	85012-3074
Phone:	6026312789
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 36470
Address 2:
City:	PHOENIX
State:	AZ
Zip:	85067
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
DAVID MATHEWS	RDA	17251409	YES		12/21/2016

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:	BARBARA CAMPBELL
Title:	COMPLIANCE SPECIALIST
Phone Number:	254-729-8002
Email Address:	BCAMPBELL@ILSAINC.COM