Notification of Changes for Business Entity
General Information
Business Entity Name:	APPLEBY & WYMAN INSURANCE AGENCY, INC.
Incorporation / Formation Date:	09/21/2017
FEIN:	821239652
Ohio License Number:	1163915
NPN:	18385184
DBA / Trade Name:	APPLEBY & WYMAN INSURANCE AGENCY
State of Domicile:	ME
County:	PENOBSCOT
Business Address
Address 1:	491 MAIN STREET
Address 2:
City:	BANGOR
State:	ME
Zip:	04401
Phone:	207-947-7345
Fax:
Business Web Site Address:
Business Email Address:	LICENSING@CROSSAGENCY.COM
Mailing Address
Address 1:	PO BOX 1388
Address 2:
City:	BANGOR
State:	ME
Zip:	04402
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	YES	Old Business Entity Name:	AW INSURANCE AGENCY, INC.
New DBA/Trade Name:	YES	New DBA/Trade Name:	CROSS INSURANCE - BEVERLY
Amend DBA/Trade Name:	YES	Old DBA/Trade Name:	APPLEBY & WYMAN INSURANE AGENC
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:	ROYCE M. CROSS
Title:	CHAIRMAN
Phone Number:	2079477345
Email Address:	LICENSING@CROSSAGENCY.COM