Notification of Changes for Business Entity
General Information
Business Entity Name:	ISM INSURANCE, INC.
Incorporation / Formation Date:
FEIN:	510324704
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	1316 N. UNION STREET
Address 2:
City:	WILMINGTON
State:	DE
Zip:	19806
Phone:	3026564944
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1316 N. UNION STREET
Address 2:
City:	WILMINGTON
State:	DE
Zip:	19806
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
ALICIA CLINGAN	AGENT	7313495	YES		01-25-2016

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:	BRENDA ANTHONY
Title:
Phone Number:	501-664-8044
Email Address:	CORPQUAL@CENTRALLICENSINGBUREAU.COM