Notification of Changes for Business Entity
General Information
Business Entity Name:	DEVONSHIRE INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	042710779
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	MA
County:	SUFFOLK
Business Address
Address 1:	200 SEAPORT BLVD.
Address 2:
City:	BOSTON
State:	MA
Zip:	02210
Phone:	6175635293
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	200 SEAPORT BLVD.
Address 2:
City:	BOSTON
State:	MA
Zip:	02210
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
GRADY, CHRISTINE R	REGISTERED REP	16103223		YES	2/26/2015
GRIFFITHS, BRIAN	REGISTERED REP	9737335		YES	2/26/2015
HARPER, WILLIAM J	REGISTERED REP	3698156		YES	2/26/2015
KELLY, DAVID G	REGISTERED REP	9682769		YES	2/26/2015
LEWIS, THOMAS W	REGISTERED REP	17403566		YES	2/26/2015
MATLOCK, DANIEL LEE	REGISTERED REP	1586687		YES	2/26/2015
MCPHERSON, DAVID S	REGISTERED REP	16699926		YES	2/26/2015
MORRIS, TROY A	REGISTERED REP	15852785		YES	2/26/2015
PERSCHON, MATTHEW B	REGISTERED REP	11482226		YES	2/26/2015
RECHTIN, TIMOTHY T	REGISTERED REP	16817777		YES	2/26/2015
SEFTON, ROSS STEVEN	REGISTERED REP	16778092		YES	2/26/2015
SHAW, KYLE M	REGISTERED REP	7616755		YES	2/26/2015
STEARNS, NANCY R	REGISTERED REP	16616048		YES	2/26/2015
TATE, MICHAEL D	REGISTERED REP	8390078		YES	2/26/2015
WATSON, JOHN A	REGISTERED REP	2425733		YES	2/26/2015

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:	AUTUMN STRONG
Title:	LICENSING SPECIALIST I
Phone Number:	8004285708
Email Address:	FIDELITY@LICENSE-SUPPORT.COM