Notification of Changes for Business Entity
General Information
Business Entity Name:	AGENCY SERVICES OF ARKANSAS, INC. DBA THE ASA GROUP
Incorporation / Formation Date:
FEIN:	62-1009542
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	AR
County:	PULASKI
Business Address
Address 1:	11807 HINSON ROAD
Address 2:
City:	LITTLE ROCK
State:	AR
Zip:	72212
Phone:	501-224-7739
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	11807 HINSON ROAD
Address 2:
City:	LITTLE ROCK
State:	AR
Zip:	72212
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
JASON VANDOUSER	AGENT	7369466	YES		08/26/2016

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:	ANDY CLAYTON
Title:	LICENSING AND CONTRACTING MANAGER
Phone Number:	501-224-7739
Email Address:	ACLAYTON@THEASAGROUP.COM