Notification of Changes for Business Entity
General Information
Business Entity Name:	AMA INSURANCE AGENCY, INC.
Incorporation / Formation Date:	03/27/1984
FEIN:	36-3305962
Ohio License Number:	24895
NPN:	66129
DBA / Trade Name:
State of Domicile:	IL
County:	COOK
Business Address
Address 1:	330 N. WABASH AVENUE
Address 2:	SUITE 39300
City:	CHICAGO
State:	IL
Zip:	60611
Phone:	800-458-5736
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	330 N. WABASH AVENUE
Address 2:	SUITE 39300
City:	CHICAGO
State:	IL
Zip:	60611
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
ALFRED DROWNE	AGENT	17966952	YES		10/31/2016
SONJA D. SMITH	AGENT	16007633	YES		10/31/2016
CAROL S. PERRONI	AGENT	2171147	YES		10/31/2016

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:	DENISE S. FRIDAY
Title:	VICE PRESIDENT
Phone Number:	312-464-5234
Email Address:	DENISE.FRIDAY@AMAINSURE.COM