Notification of Changes for Business Entity
General Information
Business Entity Name:	UNDERWRITERS ALLIANCE OF INDIANA, INC.
Incorporation / Formation Date:	09/29/2000
FEIN:	35-2120937
Ohio License Number:	41606
NPN:	3890586
DBA / Trade Name:
State of Domicile:	IN
County:	GRANT
Business Address
Address 1:	959 E. 4TH ST.
Address 2:	PO BOX 1600
City:	MARION
State:	IN
Zip:	46952
Phone:	7656642333
Fax:
Business Web Site Address:
Business Email Address:	KMILLER@INSMGT.COM
Mailing Address
Address 1:	PO BOX 1600
Address 2:
City:	MARION
State:	IN
Zip:	46952
Indicate the type of change you are seeking
Address Change:	YES
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
LAWRENCE CONNOLLY	PRESIDENT	1440216		YES	1/1/2017
KYLE STOFFEL	PRESIDENT	1452268	YES		1/1/2017

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)	NO
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?	NO
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:	STACEY KING
Title:	ADMINISTRATIVE ASSISTANT
Phone Number:	7653823027
Email Address:	SKING@INSMGT.COM