Notification of Changes for Business Entity
General Information
Business Entity Name:	SPECIALTY INSURANCE GROUP INC
Incorporation / Formation Date:
FEIN:	300756379
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	IN
County:	CARMEL
Business Address
Address 1:	111 CONGRESSIONAL BLVD STE 220
Address 2:
City:	CARMEL
State:	IN
Zip:	46032
Phone:	317-853-7050
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	111 CONGRESSIONAL BLVD STE 220
Address 2:
City:	CARMEL
State:	IN
Zip:	46032
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DARYL BRADLEY	PRESIDENT	261135983		YES	11/04/2015
FRANK LOPAPA	TREASURER	153544253		YES	11/04/2015
JODY LYNN HOLZINGER	DIRECTOR	306020367		YES	11/04/2015
MARLA KRULL PETERS	VICE PRESIDENT	286729347		YES	11/04/2015
JONATHAN ZAFFINO	PRESIDENT/COB/DIRECTOR	044703267	YES		11/04/2015
LORRAINE MILLER	VICE PRESIDENT	065489709	YES		11/04/2015
BARBARA DUNNE	VICE PRESIDENT	156600958	YES		11/04/2015
WAYNE SCHONLAND	VICE PRESIDENT/CTO	156541497	YES		11/04/2015
CRAIG HOWIE	TREASURER	142705984	YES		11/04/2015
SANJOY MULKHERJEE	SECRETARY/GEN COUNSEL/DIRECTOR	074462645	YES		11/04/2015

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)	NO
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?	NO
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 HARRIS
Title:	VICE PRESIDENT
Phone Number:	317-853-7250
Email Address:	KDPOTTS@SUPPORTIVEIS.COM