Notification of Changes for Business Entity
General Information
Business Entity Name:	MARINE AND BOND INSURANCE AGENCY, INC.
Incorporation / Formation Date:	05/21/1984
FEIN:	77-0194281
Ohio License Number:	31995
NPN:	2110846
DBA / Trade Name:
State of Domicile:	CA
County:	US
Business Address
Address 1:	56 E. MAIN ST. #200
Address 2:
City:	VENTURA
State:	CA
Zip:	93001
Phone:	805-667-8512
Fax:	805-667-8513
Business Web Site Address:
Business Email Address:	JEFF@AMERICANMARINEINSURANCE.COM
Mailing Address
Address 1:	56 E. MAIN ST. #200
Address 2:
City:	VENTURA
State:	CA
Zip:	93001
Indicate the type of change you are seeking
Address Change:	YES
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:	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:	HAILEY OVERBY
Title:	TREAS
Phone Number:	2148550737
Email Address:	HOVERBY@KENNEDYLICENSING.COM