Notification of Changes for Business Entity
General Information
Business Entity Name:	HAGERTY INSURANCE AGENCY
Incorporation / Formation Date:	01/01/2010
FEIN:	880268247
Ohio License Number:	24109
NPN:	686949
DBA / Trade Name:
State of Domicile:	MI
County:	GRAND TRAVERSE
Business Address
Address 1:	141 RIVERS EDGE DR, STE 200
Address 2:
City:	TRAVERSE CITY
State:	MI
Zip:	49684
Phone:	2319417477
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 87
Address 2:
City:	TRAVERSE CITY
State:	MI
Zip:	49685
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
ALEXANDER FEHRMAN	AGENT	18202743	YES		12/14/2016
ALEXANDRE EDGAR	AGENT	18205121	YES		12/14/2016
CHRISTINE BRADLEY	AGENT	18202746	YES		12/14/2016
DEVIN SCOTT	AGENT	18217183	YES		12/14/2016
DOUGLAS BAIRD	AGENT	7700026	YES		12/14/2016
EDWINA BURTON	AGENT	17899448	YES		12/14/2016
ELIZABETH WITHERS	AGENT	18202748	YES		12/14/2016
JULIE BLUMENREICH	AGENT	17719235	YES		12/14/2016
KYLE BURROUGHS	AGENT	18202747	YES		12/14/2016
MATTHEW ULIBARRI	AGENT	16890029	YES		12/14/2016
MICHELLE MCCLURG	AGENT	18202741	YES		12/14/2016
CODY KINNEY	AGENT	16100889		YES	12/14/2016
MELISSA BASLER	AGENT	10318137		YES	12/14/2016
TIMOTHY ONTHANK	AGENT	12482065		YES	12/14/2016
NICHOLAS HARTSUFF	AGENT	16831770		YES	12/14/2016

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:	DAVID RHINE
Title:	LICENSING COORIDNATOR
Phone Number:	2319417477
Email Address:	DRHINE@HAGERTY.COM