Notification of Changes for Business Entity
General Information
Business Entity Name:	AMWINS ACCESS INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	13-4279678
Ohio License Number:	979880
NPN:	16845413
DBA / Trade Name:
State of Domicile:	GA
County:	HENRY
Business Address
Address 1:	ONE GRESHAM LANDING
Address 2:
City:	STOCKBRIDGE
State:	GA
Zip:	30281
Phone:	678-586-2200
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	ONE GRESHAM LANDING
Address 2:
City:	STOCKBRIDGE
State:	GA
Zip:	30281
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
RICHARD REPATH	EXECUTIVE VICE PRESIDENT	5939918	YES		08/22/2016
DANIEL REPPERT	DIRECTOR PRESIDENT	000000		YES	09/22/2016
JOHN SHORT	SECRETARY	000000		YES	09/22/2016
MICHAEL VRBAN	DIRECTOR TREASURER	000000		YES	09/22/2016
RICHARD KARLBOUGH	DIRECTOR	000000		YES	09/22/2016

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:	JAMES ANTHONY GRESHAM
Title:	COO
Phone Number:	678-586-2200
Email Address:	BARBARA.THOMPSON@AMWINS.COM