Notification of Changes for Business Entity
General Information
Business Entity Name:	AS INSURANCE LLC
Incorporation / Formation Date:
FEIN:	81-4730361
Ohio License Number:	1134587
NPN:
DBA / Trade Name:
State of Domicile:	NH
County:	HILLSBOROUGH
Business Address
Address 1:	148 BROOK ST. STE 2
Address 2:
City:	MANCHESTER
State:	NH
Zip:	03104
Phone:	603-627-8000
Fax:
Business Web Site Address:	WWW.ASUREAGENCY.COM
Business Email Address:	TACHARYA@ASUREAGENCY.COM
Mailing Address
Address 1:	148 BROOK ST. STE 2
Address 2:
City:	MANCHESTER
State:	NH
Zip:	03104
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
SAVITRI KHANAL	AGENT	17208695	YES		10/01/2017
HOM N NEOPANEY	AGENT	17712291	YES		10/01/2017

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:	WILLIAM J. GILLETT
Title:	DIRECTOR
Phone Number:	603-218-9126
Email Address:	WGILLETT@ASUREAGENCY.COM