Notification of Changes for Business Entity
General Information
Business Entity Name:	ELITE MANAGING GENERAL AGENCY, LLC
Incorporation / Formation Date:
FEIN:	261759221
Ohio License Number:	1035196
NPN:	10599115
DBA / Trade Name:
State of Domicile:	PA
County:	CHESTER
Business Address
Address 1:	985 OLD EAGLE SCHOOL RD, SUITE 505
Address 2:
City:	WAYNE
State:	PA
Zip:	19087
Phone:	4845806661
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	985 OLD EAGLE SCHOOL RD, SUITE 505
Address 2:
City:	WAYNE
State:	OH
Zip:	19087
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	LEANNE MILLS - ILSA
Title:	CLIENT LIAISON SERVICES
Phone Number:	2547296141
Email Address:	LMILLS@ILSAINC.COM