Notification of Changes for Business Entity
General Information  
Business Entity Name: THE MANTOLOKIN GROUP
Incorporation / Formation Date:  
FEIN: 274165057
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: NJ
County: ESSEX
Business Address  
Address 1: 337 BLOOMFIELD AVE
Address 2:  
City: NEWARK
State: NJ
Zip: 07107
Phone: 866-860-8190
Fax:  
Business Web Site Address:  
Business Email Address: ROB@THEMANTOLOKINGROUP.COM
Mailing Address  
Address 1: 337 BLOOMFIELD AVE
Address 2:  
City: NEWARK
State: NJ
Zip: 07107
   
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
TEDESCO, ANTHONY J PRODUCER 17502102 YES   04/13/2016
WASHINGTON, CLAUDE EDWARD PRODUCER 16427516 YES   04/13/2016
PETTIFORD, GERALD PRODUCER 17059761 YES   04/13/2016
BILLINGS, JANEEN ISABELLA PRODUCER 16859132 YES   04/13/2016
SLOCKBOWER, JILLIAN PRODUCER 16945475 YES   04/13/2016
LAWSON, JORRELL PRODUCER 17447027 YES   04/13/2016
COVINGTON, MYRON PRODUCER 17322925 YES   04/13/2016
BARBER, SQUINN WILLIAM PRODUCER 16956253 YES   04/13/2016
FEDOR, WILLIAM J PRODUCER 17430286 YES   04/13/2016
           
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) NO
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? NO
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: DANIEL GARAVUSO
Title: DIRECTOR, COMPLIANCE
Phone Number: 8133971493
Email Address: DGARAVUSO@HIIQUOTE.COM