Notification of Changes for Business Entity
General Information
Business Entity Name:	AMTRUST NORTH AMERICA, INC.
Incorporation / Formation Date:
FEIN:	34-1965476
Ohio License Number:	30378
NPN:	7075035
DBA / Trade Name:
State of Domicile:	NY
County:	NEW YORK
Business Address
Address 1:	59 MAIDEN LANE
Address 2:	43RD FLOOR
City:	NEW YORK
State:	NY
Zip:	10038
Phone:	(866) 203-3037
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	400 EXECUTIVE BLVD
Address 2:	4TH FLOOR
City:	SOUTHINGTON
State:	CT
Zip:	06489
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DELYNN D. TRIVISON	RDA	950479	YES		01/12/2018
STUART D. HOLLANDER	RDA	3393774		YES	01/12/2018

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:	CATHY KIMMEY
Title:	LICENSING SPECIALIST
Phone Number:	(972) 788-6811
Email Address:	PRODUCER.LICENSING@AMTRUSTGROUP.COM