Notification of Changes for Business Entity
General Information
Business Entity Name:	LEVERITY INSURANCE GROUP INC
Incorporation / Formation Date:
FEIN:	27-3904761
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	CUYAHOGA
Business Address
Address 1:	3737 PARK EAST DR #204
Address 2:
City:	BEACHWOOD
State:	OH
Zip:	44122
Phone:	800-748-0351
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	3737 PARK EAST DR #204
Address 2:
City:	BEACHWOOD
State:	OH
Zip:	44122
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
JOSEPH CORRADETTI	PRODUCER	7325428		YES	10/8/2018

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:	MEAGAN BICKEL
Title:	LICENSING SPECIALIST
Phone Number:	919-653-5213
Email Address:	MEAGAN.BICKEL@REGED.COM