Notification of Changes for Business Entity
General Information
Business Entity Name:	CES INSURANCE AGENCY, INC
Incorporation / Formation Date:
FEIN:	04-2865307
Ohio License Number:	29221
NPN:
DBA / Trade Name:
State of Domicile:	MA
County:	MIDDLESEX
Business Address
Address 1:	29 SAWYER ROAD
Address 2:
City:	WALTHAM
State:	MA
Zip:	02453
Phone:	8002510080
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	LICENSING@COMMONWEALTH.COM
Address 2:
City:	WALTHAM
State:	MA
Zip:	02453
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
BRADLEY W. PREWITT	NONRESIDENT AGENT	5069495	YES		09/02/2016

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)	NO
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?	NO
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:	RENEE LEBARON
Title:	LICENSING SPECIALIST
Phone Number:	7817360700
Email Address:	RLEBARON@COMMONWEALTH.COM