Notification of Changes for Business Entity
General Information
Business Entity Name:	AMERICAN SERVICE INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	274829115
Ohio License Number:	992051
NPN:	16460754
DBA / Trade Name:
State of Domicile:	TX
County:	TARRANT
Business Address
Address 1:	3216 FRIENDLY LANE
Address 2:	SUITE B
City:	HALTOM CITY
State:	TX
Zip:	76117
Phone:	6827309595
Fax:
Business Web Site Address:
Business Email Address:	DGARAVUSO@HIIQUOTE.COM
Mailing Address
Address 1:	3216 FRIENDLY LANE
Address 2:	SUITE B
City:	HALTOM CITY
State:	TX
Zip:	76117
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
JONATHAN M RODRIGUEZ	PRODUCER	17624647	YES		03/22/2016
KALENA EVETTE TURNBOW	PRODUCER	16875142	YES		03/22/2016
KEVIN JAMES WESTER	PRODUCER	16208015	YES		03/22/2016
KRISTIN ARLINE BROWN	PRODUCER	16616483	YES		03/22/2016
KRYSTLE BOWMAN	PRODUCER	17030013	YES		03/22/2016
LACI LORRAINE TRIBBLE	PRODUCER	17038118	YES		03/22/2016
LEONARD CHARLES WESLEY	PRODUCER	16869306	YES		03/22/2016
MARIA MERCEDES PEREZ	PRODUCER	16861263	YES		03/22/2016
STARLA RENEE GRAVES	PRODUCER	17388438	YES		03/22/2016
MELISSA MICHELLE HERNANDEZ	PRODUCER	17356531	YES		03/22/2016
MICKEY JOE WRAGG	PRODUCER	16880010	YES		03/22/2016
PEYTON RAE GONZALES-PENA	PRODUCER	17839585	YES		03/22/2016
RICHARD GLYN LANDIS	PRODUCER	16879926	YES		03/22/2016
SAMUEL LOUIS HODGE	PRODUCER	17153750	YES		03/22/2016
SHELIA ANN SANCHEZ	PRODUCER	16939521	YES		03/22/2016

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:	DANIEL GARAVUSO
Title:	DIRECTOR, COMPLIANCE
Phone Number:	8133971493
Email Address:	DGARAVUSO@HIIQUOTE.COM