Notification of Changes for Business Entity
General Information
Business Entity Name:	INTERCITY AGENCY INC
Incorporation / Formation Date:
FEIN:	111686949
Ohio License Number:	38985
NPN:	2013749
DBA / Trade Name:
State of Domicile:	NY
County:	NASSAU
Business Address
Address 1:	1983 MARCUS AVENUE
Address 2:	SUITE 100
City:	LAKE SUCCESS
State:	NY
Zip:	11042
Phone:	(718) 279-7700
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1983 MARCUS AVENUE
Address 2:	SUITE 100
City:	LAKE SUCCESS
State:	NY
Zip:	11042
Indicate the type of change you are seeking
Address Change:	YES
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

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:	FITZGERALD VENTURA
Title:	PRINCIPAL
Phone Number:	(718) 279-7700
Email Address:	FITZ.VENTURA@INTERCITYAGENCY.COM