Notification of Changes for Business Entity
General Information
Business Entity Name:	AMERICAN GUARDIAN INSURANCE SERVICES, INC.
Incorporation / Formation Date:
FEIN:	90-1025950
Ohio License Number:	1018287
NPN:	17140908
DBA / Trade Name:
State of Domicile:	IL
County:	DUPAGE
Business Address
Address 1:	4450 WEAVER PARKWAY
Address 2:
City:	WARRENVILLE
State:	IL
Zip:	60555
Phone:	630-534-4114
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	4450 WEAVER PARKWAY
Address 2:
City:	WARRENVILLE
State:	IL
Zip:	60555
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
JON A. ANDERSON	RDA	1945673	YES		10/13/2017
STEVEN E. FREEDMAN	RDA	8782742		YES	10/13/2017

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)
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:	KRISTINA SJURSET
Title:	COMPLIANCE ASSOCIATE
Phone Number:	630-386-4210
Email Address:	KSJURSET@AGWSINC.COM