Notification of Changes for Business Entity
General Information  
Business Entity Name: CHUBB INSURANCE SOLUTIONS AGENCY INC.
Incorporation / Formation Date:  
FEIN: 51-0391861
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: DE
County: NEW CASTLE
Business Address  
Address 1: 1 BEAVER VALLEY RD
Address 2:  
City: WILMINGTON
State: DE
Zip: 19803
Phone: 215-640-2590
Fax:  
Business Web Site Address:  
Business Email Address:  
Mailing Address  
Address 1: 436 WALNUT ST
Address 2:  
City: PHILADELPHIA
State: PA
Zip: 19106
   
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
GARY ROTENBURY OFFICER 200486484   YES 08/07/2018
INA HOLDINGS CORP OWNER 510369230   YES 08/07/2018
JON BIDWELL DIRECTOR 261592634   YES 08/07/2018
JOSEPH JORDAN TREASURER N/A   YES 08/07/2018
KEVIN HOGAN DIRECTOR 045748638   YES 08/07/2018
MARY BOYD DIRECTOR N/A   YES 08/07/2018
MATTHEW SCHLINDWEIN OFFICER 147440766   YES 08/07/2018
PATTY LEE VICE PRESIDENT N/A   YES 08/07/2018
ROBERT COURTEMANCHE DIRECTOR/OFFICER/PRESIDENT N/A   YES 08/07/2018
SUSAN VELLA DIRECTOR 161604245   YES 08/07/2018
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: JANNA BELL
Title: LICENSING ADMIN
Phone Number: 812-494-2476
Email Address: JBELL@SUPPORTIVEIS.COM