Notification of Changes for Business Entity
General Information
Business Entity Name:	AMVENTURE INSURANCE AGENCY, INC
Incorporation / Formation Date:
FEIN:	813326574
Ohio License Number:	1117918
NPN:	18035589
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	2711 CENTERVILLE RD, STE 400
Address 2:
City:	WILMINGTON
State:	DE
Zip:	19808
Phone:	8605713104
Fax:
Business Web Site Address:
Business Email Address:	PRODUCER.LICENSING@AMTRUSTGROUP.COM
Mailing Address
Address 1:	400 EXECUTIVE BLVD 4TH FLOOR
Address 2:
City:	SOUTHINGTON
State:	CT
Zip:	06489
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
FRANK ZIBERT	AGENT	8159611		YES	06/06/2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
AMTRUST UNDERWRITERS

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:	ZACHARY CHAMBERLAND
Title:	COMPLIANCE SPECIALIST
Phone Number:	8605713104
Email Address:	APPOINTMENTS@AMTRUSTGROUP.COM