Notification of Changes for Business Entity
General Information
Business Entity Name:	DEVONSHIRE INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	042710779
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	MA
County:	SUFFOLK
Business Address
Address 1:	200 SEAPORT BLVD.
Address 2:
City:	BOSTON
State:	MA
Zip:	02210
Phone:	6175635293
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	200 SEAPORT BLVD.
Address 2:
City:	BOSTON
State:	MA
Zip:	02210
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
HOLLON II, JESS A	REGISTERED REP	17599548		YES	4/25/2016
KALWAS, WILLIAM H	REGISTERED REP	8446928		YES	4/25/2016
LANGLER, NICHOLAS A	REGISTERED REP	16867119		YES	4/25/2016
LUCERO, STEPHEN M	REGISTERED REP	9521813		YES	4/25/2016
MARQUARDT, RYAN H	REGISTERED REP	17228419		YES	4/25/2016
MCGAHREN, JOSEPH G	REGISTERED REP	1082444		YES	4/25/2016
MERLING, KEVIN	REGISTERED REP	15711041		YES	4/25/2016
O'BRIEN, JANET A	REGISTERED REP	16563716		YES	4/25/2016
PEARSON, TIMOTHY PATRICK	REGISTERED REP	727689		YES	4/25/2016
PETTY, BOYD H	REGISTERED REP	8611992		YES	4/25/2016
PRESTON, THOMAS E	REGISTERED REP	695799		YES	4/25/2016
RICHARDSON, KATHERINE M	REGISTERED REP	15762161		YES	4/25/2016
ROSS IV, WILLIAM M	REGISTERED REP	1943893		YES	4/25/2016
VAN WAGENEN, JOHN P	REGISTERED REP	8478323		YES	4/25/2016

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:	AUTUMN STRONG
Title:	LICENSING SPECIALIST I
Phone Number:	8004285708
Email Address:	FIDELITY@LICENSE-SUPPORT.COM