Notification of Changes for Business Entity
General Information
Business Entity Name:	AMICA GENERAL AGENCY, LLC
Incorporation / Formation Date:	05/04/1987
FEIN:	050430401
Ohio License Number:	23836
NPN:	654114
DBA / Trade Name:
State of Domicile:	RI
County:	PROVIDENCE
Business Address
Address 1:	ONE HUNDRED AMICA WAY
Address 2:
City:	LINCOLN
State:	RI
Zip:	02865
Phone:	8006526422
Fax:
Business Web Site Address:
Business Email Address:	AMICALICENSING@AMICA.COM
Mailing Address
Address 1:	ONE HUNDRED AMICA WAY
Address 2:
City:	LINCOLN
State:	RI
Zip:	02865
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	AMICA GENERAL AGENCY, INC.
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:	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:	ROBERT A. DIMUCCIO
Title:	MANAGER
Phone Number:	800-652-6422
Email Address:	AMICALICENSING@AMICA.COM