Notification of Changes for Business Entity
General Information
Business Entity Name:	AEGIS GENERAL INSURANCE AGENCY INC
Incorporation / Formation Date:	03/29/1976
FEIN:	231745172
Ohio License Number:	27351
NPN:	957388
DBA / Trade Name:
State of Domicile:	PA
County:	HARRISBURG
Business Address
Address 1:	4507 N FRONT STREET STE 200
Address 2:
City:	HARRISBURG
State:	PA
Zip:	17110
Phone:	7176579671
Fax:	7176575425
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 3153
Address 2:
City:	HARRISBURG
State:	PA
Zip:	17105
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
WILLIAM LANE	RDA	624418		YES	03/09/2017
JOSEPH HARNER	RDA	8016111	YES		03/09/2017
ROBERT LARGE	RDA	8028274	YES		03/09/2017
MARK NORDSTROM	RDA	77224	YES		03/09/2017

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:	CHRISTY KRICK
Title:	LICENSING ADMINISTRATOR
Phone Number:	8124942472
Email Address:	CKRICK@SUPPORTIVEIS.COM