Notification of Changes for Business Entity
General Information  
Business Entity Name: AMVENTURE INSURANCE AGENCY, INC.
Incorporation / Formation Date:  
FEIN: 813326574
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: DE
County: NEW CASTLE
Business Address  
Address 1: 2711 CENTERVILLE ROAD, SUITE 400
Address 2:  
City: WILMINGTON
State: DE
Zip: 19808
Phone: 8605713104
Fax:  
Business Web Site Address:  
Business Email Address:  
Mailing Address  
Address 1: 800 SUPERIOR AVE, E., 21ST FLOOR
Address 2:  
City: CLEVELAND
State: OH
Zip: 44114
   
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
DENZEL MUTLAQ AGENT 18806471   YES 12/03/2018
JASON COLUCCI AGENT 18790801   YES 12/03/2018
LANE ANDEREW WOODRING AGENT 18669699   YES 12/03/2018
LAURA JACLYN DYNDA AGENT 18668525   YES 12/03/2018
MILTON TREVON HOFFMAN AGENT 18802046   YES 12/03/2018
SAMANTHA NICOLE PURK AGENT 18790830   YES 12/03/2018
           
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: MONICA R. BROPHY
Title: COMPLIANCE SPECIALIST II
Phone Number: 8605713104
Email Address: PRODUCER.LICENSING@AMTRUSTGROUP.COM