Notification of Changes for Business Entity
General Information
Business Entity Name:	OMEGA INSURANCE AGENCY INC.
Incorporation / Formation Date:
FEIN:	27-4098202
Ohio License Number:	1056853
NPN:
DBA / Trade Name:
State of Domicile:	NY
County:	SUFFOLK
Business Address
Address 1:	33 WALT WHITMAN ROAD, SUITE 107
Address 2:
City:	HUNTINGTON STATION
State:	NY
Zip:	11746
Phone:	631-923-2520
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	33 WALT WHITMAN ROAD, SUITE 107
Address 2:
City:	HUNTINGTON STATION
State:	NY
Zip:	11746
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:	AGHA ALI
Title:	PRESIDENT
Phone Number:	631-923-2520
Email Address:	AGHA.ALI@OMEGAINSURANCEAGENCY.COM