Notification of Changes for Business Entity
General Information
Business Entity Name:	AGRI-SERVICES AGENCY LLC
Incorporation / Formation Date:	04/01/1999
FEIN:	16-1564790
Ohio License Number:	29097
NPN:	3218973
DBA / Trade Name:
State of Domicile:	NY
County:	ONONDAGA
Business Address
Address 1:	5001 BRITTONFIELD PARKWAY
Address 2:
City:	EAST SYRACUSE
State:	NY
Zip:	13057
Phone:	315-433-2332
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 4910
Address 2:
City:	SYRACUSE
State:	NY
Zip:	13221
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
CHRISTINE BRODEUR WICKHAM	DIRECTOR	1216636	YES		11/06/18
KYLE CRAIG FERGASON	PRODUCER	1217307	YES		11/06/18

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:	JESSICA ROOT
Title:	LICENSING COORDINATOR
Phone Number:	866-426-6667
Email Address:	JROOT@GANNONASSOCIATES.COM