Notification of Changes for Business Entity
General Information
Business Entity Name:	AMTRUST NORTH AMERICA, INC.
Incorporation / Formation Date:
FEIN:	34-1965476
Ohio License Number:
NPN:	7075035
DBA / Trade Name:
State of Domicile:	NY
County:	NEW YORK
Business Address
Address 1:	59 MAIDEN LANE, 43RD FLOOR
Address 2:
City:	NEW YORK
State:	NY
Zip:	10038
Phone:	860-571-3104
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	400 EXECUTIVE BLVD, 4TH FLOOR
Address 2:
City:	SOUTHINGTON
State:	CT
Zip:	06489
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
ARIEL GORELIK	CIO, EXECUTIVE VICE PRESIDENT	748-78-7721	YES		06/30/2018
DANIEL HICKEY	GRP CHIEF UNDERWRITING OFFICER	459-17-3469	YES		06/30/2018
SUSAN HOWE	VICE PRESIDENT	106-58-2291	YES		06/30/2018
DELYNN TRIVISON	EXECUTIVE VICE PRESIDENT	266-65-1847	YES		06/30/2018
JEFFREY LEO	VICE PRESIDENT	199-48-5001		YES	06/30/2018

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:	COMPLIANCE SPECIALIST I
Phone Number:	972-788-6811
Email Address:	PRODUCER.LICENSING@AMTRUSTGROUP.COM