Notification of Changes for Business Entity
General Information
Business Entity Name:	WILLIS OF PENNSYLVANIA, INC.
Incorporation / Formation Date:
FEIN:	251201243
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	PA
County:	ALLEGHENY
Business Address
Address 1:	ONE PPG PLACE
Address 2:	10TH FLOOR
City:	PITTSBURGH
State:	PA
Zip:	15222
Phone:	615-872-3447
Fax:	6158664184
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	ONE PPG PLACE
Address 2:	10TH FLOOR
City:	PITTSBURGH
State:	PA
Zip:	15222
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
JOHN R. NISSLEY	VICE PRESIDENT	16438440		YES	11/18/2015

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:	TRACIE HITE
Title:	LICENSING ADMINISTRATOR
Phone Number:	615-872-3447
Email Address:	TRACIE.HITE@WILLIS.COM