Notification of Changes for Business Entity
General Information
Business Entity Name:	PLAINVILLE CENTER INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	06-1348178
Ohio License Number:	950014
NPN:
DBA / Trade Name:
State of Domicile:	CT
County:	HARTFORD
Business Address
Address 1:	200 EXECUTIVE BLVD
Address 2:
City:	SOUTHINGTON
State:	CT
Zip:	06489
Phone:	860-747-9207
Fax:	860-747-2720
Business Web Site Address:
Business Email Address:	INFO@CTCASUALTY.COM
Mailing Address
Address 1:	P O BOX 490
Address 2:
City:	SOUTHINGTON
State:	CT
Zip:	06489
Indicate the type of change you are seeking
Address Change:	YES
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:	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:	BEVERLY LANCASTER
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-494-2478
Email Address:	BJLANCASTER@SUPPORTIVEIS.COM