Notification of Changes for Business Entity
General Information
Business Entity Name:	HAGERTY INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	88-0268247
Ohio License Number:	24109
NPN:
DBA / Trade Name:
State of Domicile:	MI
County:	GRAND TRAVERSE
Business Address
Address 1:	141 RIVERS EDGE DR
Address 2:	SUITE 200
City:	TRAVERSE CITY
State:	MI
Zip:	49684
Phone:	2319417477
Fax:
Business Web Site Address:
Business Email Address:	MEBY@HAGERTY.COM
Mailing Address
Address 1:	PO BOX 87
Address 2:
City:	TRAVERSE CITY
State:	MI
Zip:	49685
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
JENNY ALBRECHT	AGENT	18699483	YES		05/01/2018
THOMAS BISBEE	AGENT	18699510	YES		05/01/2018
EVAN COLE	AGENT	18699484	YES		05/01/2018
NICOLE DALGLEISH	AGENT	18699511	YES		05/01/2018
PAUL DONATHAN	AGENT	16754470	YES		05/01/2018
COURTNEY GARBER	AGENT	17173293	YES		05/01/2018
KATELYN HUBER	AGENT	18699571	YES		05/01/2018
ANDREW JASON	AGENT	18699570	YES		05/01/2018
NICHOLAS NIERGARTH	AGENT	18699548	YES		05/01/2018
ANNA O'HARA	AGENT	18699565	YES		05/01/2018
STEVEN PHILIPS	AGENT	14312556	YES		05/01/2018
MICHAEL SHREVES	AGENT	18702191	YES		05/01/2018
JUSTINE SOURIE	AGENT	18703523	YES		05/01/2018
BRITTANY SPENCER	AGENT	18702310	YES		05/01/2018
JAMESON TOMA	AGENT	18702269	YES		05/01/2018

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:	MEAGAN EBY
Title:	LICENSING COORDINATOR
Phone Number:	2319296092
Email Address:	MEBY@HAGERTY.COM