Notification of Changes for Business Entity
General Information
Business Entity Name:	AMICA GENERAL AGENCY, LLC
Incorporation / Formation Date:
FEIN:	050430401
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	RI
County:	PROVIDENCE
Business Address
Address 1:	100 AMICA WAY
Address 2:
City:	LINCOLN
State:	RI
Zip:	02865
Phone:	800-652-6422
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 6008
Address 2:
City:	PROVIDENCE
State:	RI
Zip:	02940
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
JENNIFER WUNDERLICH	PRODUCER	7875881	YES		12/1/2017
JOSEPH DAVID AGNOLI	PRODUCER	9074711	YES		12/1/2017
DAVID RAYMOND DUFRESNE	PRODUCER	400600	YES		12/1/2017
KAREN ELIZABETH NORMANDIN	PRODUCER	8578732	YES		12/1/2017
WILLIE RAYMOND BONNEAU	PRODUCER	13016360	YES		12/1/2017
SUSAN ANN CESARONI	PRODUCER	11509939	YES		12/1/2017
MARISA ANN RODO	PRODUCER	17696427	YES		12/1/2017
BRADLEY ANDY THOMAS	PRODUCER	17618814	YES		12/1/2017
WHITTNEY WHEELER	PRODUCER	17512713	YES		12/1/2017
LUIS FILIPE OLIVEIRA	PRODUCER	17490268	YES		12/1/2017
MONICA BOECKMAN	PRODUCER	17837088	YES		12/1/2017
ALBERTO TOCA	PRODUCER	18383684	YES		12/1/2017
VAN SIMONE HOLDER	PRODUCER	18390135	YES		12/1/2017
JASON METZGER	PRODUCER	17061282	YES		12/1/2017
ZACHARY KNUDSEN	PRODUCER	16421650	YES		12/1/2017

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)
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:	DINARI DUPONT
Title:	ASSISTANT VICE PRESIDENT, SCS
Phone Number:	800-652-6422
Email Address:	DDUPONT@AMICA.COM