Notification of Changes for Business Entity
General Information
Business Entity Name:	STATE FUND INSURANCE
Incorporation / Formation Date:
FEIN:	043240126
Ohio License Number:	42408
NPN:	3528799
DBA / Trade Name:
State of Domicile:	MA
County:	US
Business Address
Address 1:	100 SUMMER ST SUITE 1601
Address 2:
City:	BOSTON
State:	MA
Zip:	02110
Phone:	6179569999
Fax:	6174232233
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	100 SUMMER ST SUITE 1601
Address 2:
City:	BOSTON
State:	MA
Zip:	02110
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
JOHN WHELPLEY	MANAGER	1140068	YES		09/19/2017
STEVEN DICLEMENTE	PRESIDENT	838252		YES	09/19/2017

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:	MARIAH MEDEIROS
Title:	MANAGER
Phone Number:	6179569999
Email Address:	MARIAH@STATEFUNDINSURANCE.COM