Notification of Changes for Business Entity
General Information  
Business Entity Name: CHUBB INSURANCE SOLUTIONS AGENCY INC
Incorporation / Formation Date:  
FEIN: 510391861
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: DE
County: NEW CASTLE
Business Address  
Address 1: 1 BEAVER VALLEY RD
Address 2:  
City: WILMINGTON
State: DE
Zip: 19803
Phone: 215-640-2590
Fax:  
Business Web Site Address:  
Business Email Address:  
Mailing Address  
Address 1: 436 WALNUT ST
Address 2:  
City: PHILADELPHIA
State: PA
Zip: 19106
   
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
           
Members, Owners, Partners, Officers and Directors
Name Title Identifying # Add Delete Eff. Date
AUDRA FOGLIETTA TREASURER 157685267   YES 08/07/2018
JOHN BUCKLEY TREASURER 463615259 YES   08/07/2018
JILL SACHS ASST SECRETARY 168546222 YES   08/07/2018
NEELAM PATEL DIRECTOR 173780583 YES   08/07/2018
ANTHONY FRANCOLINO OFFICER 155423425   YES 08/07/2018
AUDREY SAMERS DIRECTOR 043460964   YES 08/07/2018
BRANDON PEENE VICE PRESIDENT/SECRETARY 157908373   YES 08/07/2018
CARMINE GIGANTE OFFICER N/A   YES 08/07/2018
DARLENE RAPHAEL VICE PRESIDENT/DIRECTOR N/A   YES 08/07/2018
DOUGLAS NORDSTROM TREASURER/DIRECTOR N/A   YES 08/07/2018
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: JANNA BELL
Title: LICENSING ADMIN
Phone Number: 812-494-2476
Email Address: JBELL@SUPPORTIVEIS.COM