Notification of Changes for Business Entity
General Information
Business Entity Name:	ASSURANT INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	41-1254595
Ohio License Number:	23336
NPN:	49357
DBA / Trade Name:
State of Domicile:	MN
County:	USA
Business Address
Address 1:	500 BIELENBURG DR STE 400
Address 2:
City:	WOODBURY
State:	MN
Zip:	55125
Phone:	6513615771
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	440 MT RUSHMORE RD
Address 2:
City:	RAPID CITY
State:	SD
Zip:	57701
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
SANDRA LUISI	PRODUCER	5748098	YES		01/23/18
MARIE STEWART	PRODUCER	6273498	YES		01/23/18
JENNIFER BADIUK	PRODUCER	5748099		YES	02/01/18

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:	SUSAN ABLER-GREGG
Title:	LICENSING COORDINATOR
Phone Number:	605-719-0371
Email Address:	SUSAN.ABLER-GREGG@ASSURANT.COM