Notification of Changes for Business Entity
General Information
Business Entity Name:	HAGERTY INSURANCE AGENCY
Incorporation / Formation Date:	01/01/2010
FEIN:	880268247
Ohio License Number:	24109
NPN:	686949
DBA / Trade Name:
State of Domicile:	OH
County:	GRAND TRAVERSE
Business Address
Address 1:	141 RIVERS EDGE DR, STE 200
Address 2:
City:	TRAVERSE CITY
State:	OH
Zip:	49684
Phone:	2319417477
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 87
Address 2:
City:	TRAVERSE CITY
State:	OH
Zip:	49685
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
KRISTEN GRAY	AGENT	1133880	YES		01/18/2017

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:	DAVID RHINE
Title:	LICENSING COORIDNATOR
Phone Number:	2319417477
Email Address:	DRHINE@HAGERTY.COM