Notification of Changes for Business Entity
General Information
Business Entity Name:	ASSUREDPARTNERS OF WEST VIRGINIA, LLC
Incorporation / Formation Date:	10/24/20112
FEIN:	90-0897225
Ohio License Number:	978046, 1105162
NPN:	16808678
DBA / Trade Name:
State of Domicile:	WV
County:	CABELL
Business Address
Address 1:	ONE INSURANCE WAY SUITE 10
Address 2:
City:	ONA
State:	WV
Zip:	25545
Phone:	9736692301
Fax:
Business Web Site Address:
Business Email Address:	SLAWRENCE@JAMISONGROUP.COM
Mailing Address
Address 1:	20 COMMERCE DR., SECOND FLOOR
Address 2:
City:	CRANFORD
State:	NJ
Zip:	07016
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
ANGELA DROOK	VP	8099851	YES		05/19/2017

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:	ERIC ANDERSON
Title:	SVP
Phone Number:	9736692301
Email Address:	SLAWRENCE@JAMISONGROUP.COM