Notification of Changes for Business Entity
General Information
Business Entity Name:	SYCAMORE INS AGENCY INC
Incorporation / Formation Date:
FEIN:	37-1690754
Ohio License Number:	970934
NPN:
DBA / Trade Name:
State of Domicile:	MI
County:	OAKLAND
Business Address
Address 1:	550 WEST MERRILL STREET, SUITE 200
Address 2:
City:	BIRMINGHAM
State:	MI
Zip:	48009
Phone:	248-559-0840
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	550 WEST MERRILL ST, STE. 200
Address 2:
City:	BIRMINGHAM
State:	MI
Zip:	48009
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	YES	New DBA/Trade Name:	BLUE SPRUCE UNDERWRITERS
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

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:	ROCHELLE KAPLAN-RUDOLPH
Title:	ASSISTANT SECRETARY
Phone Number:	248-559-0840
Email Address:	PMCKINNON@CONIFERINSURANCE.COM