Notification of Changes for Business Entity
General Information
Business Entity Name:	HIIG UNDERWRITERS AGENCY, INC
Incorporation / Formation Date:
FEIN:	76-0165558
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	TX
County:	HARRIS
Business Address
Address 1:	800 GESSNER STE 600
Address 2:
City:	HOUSTON
State:	TX
Zip:	77024
Phone:	713-935-7400
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	800 GESSNER STE 600
Address 2:
City:	HOUSTON
State:	TX
Zip:	77024
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
DONNA GREEN	AGENT, VP, OFFICER, TREASURER	11533752		YES	11-06-2017
MICHAEL SCHMIDT	VP	366114		YES	11-06-2017

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:	KARI SMITH
Title:	LICENSING ADMIN.
Phone Number:	812-886-0191
Email Address:	KNSMITH@SUPPORTIVEIS.COM