Notification of Changes for Business Entity
General Information
Business Entity Name:	AMERICAN COLLECTORS INSURANCE
Incorporation / Formation Date:
FEIN:	611723442
Ohio License Number:	1019930
NPN:	17203119
DBA / Trade Name:
State of Domicile:	NJ
County:	CAMDEN
Business Address
Address 1:	555 NORTH LANE
Address 2:	SUITE 6060
City:	CONSHOHOCKEN
State:	PA
Zip:	19428
Phone:	6109419877
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	496 KINGS HWY N
Address 2:
City:	CHERRY HILL
State:	NJ
Zip:	08002
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
STEPHEN BIRD	UNDERWRITER	1128805		YES	6/22/2017

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)	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:	MARTINA TRAVIS
Title:	HR & PAYROLL MANAGER
Phone Number:	8567797212
Email Address:	LICENSING@AMERICANCOLLECTORS.COM