Notification of Changes for Business Entity
General Information
Business Entity Name:	CNH INDUSTRIAL INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	39-1867188
Ohio License Number:
NPN:	3688598
DBA / Trade Name:
State of Domicile:	WI
County:	KENOSHA
Business Address
Address 1:	104 CORPORATE DR STE 200
Address 2:
City:	PLEASANT PRAIRIE
State:	WI
Zip:	53158
Phone:	860-571-3104
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	800 SUPERIOR AVE FL 21
Address 2:
City:	CLEVELAND
State:	OH
Zip:	44114
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DAVID KOCOUREK	PRESIDENT	329-60-3000	YES		06/05/2018

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:	CATHY KIMMEY
Title:	LICENSING SPECIALIST
Phone Number:	972-788-6811
Email Address:	PRODUCER.LICENSING@AMTRUSTGROUP.COM