Notification of Changes for Business Entity
General Information
Business Entity Name:	ASHLEY INSURANCE GROUP, LTD.
Incorporation / Formation Date:	06-12-2002
FEIN:	03-0461383
Ohio License Number:	27847
NPN:	7332744
DBA / Trade Name:
State of Domicile:	OH
County:	LUCAS
Business Address
Address 1:	1645 INDIAN WOOD CIRCLE
Address 2:	SUITE 203
City:	MAUMEE
State:	OH
Zip:	43537
Phone:	419-624-9810
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	165 JACKSON ST.
Address 2:
City:	SANDUSKY
State:	OH
Zip:	44870
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
NOAH J. INTAGLIATA	BENEFIT SPECIALIST	292961941		YES	12-22-2017
JADE H. ANDRAKO	SENIOR ACCOUNT MANAGER	395940704	YES		01-02-2018

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:	TONI PENDLETON
Title:	EXECUTIVE ASSISTANT/ASHLEY INSURANCE GROUP
Phone Number:	419-502-2488
Email Address:	TONIP@THEASHLEYGROUP.COM