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
BOULANGER, JENNIFER L	REGISTERED REP	7903226		YES	2/26/2015
CALL, ZACCARY S	REGISTERED REP	17181083		YES	2/26/2015
GUERRERO IV, GUSTAVO A	REGISTERED REP	1303207		YES	2/26/2015
KELLEY, PAUL H	REGISTERED REP	6411045		YES	2/26/2015
KENNEDY, SEAN J	REGISTERED REP	7487562		YES	2/26/2015
POWELL, BRENDEN J	REGISTERED REP	16423237		YES	2/26/2015
ROSS, MAUREEN O	REGISTERED REP	16418020		YES	2/26/2015
SHAVER, HERBERT D	REGISTERED REP	1115149		YES	2/26/2015
SMITH, TRENT S	REGISTERED REP	8108232		YES	2/26/2015
TEOFILAK, CHRISTOPHER S	REGISTERED REP	16508256		YES	2/26/2015
ALFORD, JEFFREY L	REGISTERED REP	7213372		YES	2/26/2015
CHECKETTS, ERIC	REGISTERED REP	8783699		YES	2/26/2015
DAVIS, BENJAMIN	REGISTERED REP	13928887		YES	2/26/2015
DUDLEY, JASON P	REGISTERED REP	17221800		YES	2/26/2015
ELDREDGE, PHILIP D	REGISTERED REP	7142007		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