Notification of Changes for Business Entity
General Information
Business Entity Name:	CHUBB INSURANCE SOLUTIONS AGENCY INC
Incorporation / Formation Date:
FEIN:	223197410
Ohio License Number:	24012
NPN:	661267
DBA / Trade Name:
State of Domicile:	OH
County:	HUNTERDON
Business Address
Address 1:	202 HALLS MILL ROAD
Address 2:
City:	WHITEHOUSE STATION
State:	NJ
Zip:	08889
Phone:	9085722371
Fax:	8883827115
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	202 HALLS MILL ROAD
Address 2:
City:	WHITEHOUSE STATION
State:	NJ
Zip:	08889
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
AMIE BASS	PRODUCER	8015275	YES		02/08/2017

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:	CHRISTY KRICK
Title:	LICENSING ADMINISTRATOR
Phone Number:	81249424725
Email Address:	CKRICK@SUPPORTIVEIS.COM