Notification of Changes for Business Entity
General Information
Business Entity Name:	MACKINAW UNDERWRITERS INC.
Incorporation / Formation Date:	06/13/2008
FEIN:	711051888
Ohio License Number:	38511 / 39280
NPN:	11449138
DBA / Trade Name:
State of Domicile:	MI
County:	WAYNE
Business Address
Address 1:	11801 GRAND RIVER AVENUE
Address 2:
City:	BRIGHTON
State:	MI
Zip:	48116
Phone:	2482048222
Fax:
Business Web Site Address:
Business Email Address:	DMERCURIO@MEADOWBROOK.COM
Mailing Address
Address 1:	11801 GRAND RIVER AVENUE
Address 2:
City:	BRIGHTON
State:	MI
Zip:	48116
Indicate the type of change you are seeking
Address Change:	YES
Business Entity Name Change:	YES	Old Business Entity Name:	MARKETPLUS INSURANCE AGENCY, I
New DBA/Trade Name:	YES	New DBA/Trade Name:	MARKETPLUS INSURANCE AGENCY, I
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:	KENN ALLEN
Title:	VICE PRESIDENT
Phone Number:	248-358-1100
Email Address:	DMERCURIO@MEADOWBROOK.COM