Notification of Changes for Business Entity
General Information
Business Entity Name:	MADISON INSURANCE GROUP, INC
Incorporation / Formation Date:	03/31/2009
FEIN:	26-4580233
Ohio License Number:	40331
NPN:	13654314
DBA / Trade Name:
State of Domicile:	OH
County:	40331
Business Address
Address 1:	ONE HARBISON WAY
Address 2:	BROOKSIDE OFFICE BLDG, SUITE 109
City:	COLUMBIA
State:	SC
Zip:	29212
Phone:	865-482-8182
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 800
Address 2:
City:	OAK RIDGE
State:	TN
Zip:	37831
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:	DONNA L STEELE
Title:	LICENSING SPECIALIST
Phone Number:	8654251083
Email Address:	LICENSING@APPUND.COM