Notification of Changes for Business Entity
General Information
Business Entity Name:	CIA INSURANCE AGENCY, INC.
Incorporation / Formation Date:	08/12/2016
FEIN:	81-3758552
Ohio License Number:	1190588
NPN:	18097957
DBA / Trade Name:
State of Domicile:	ME
County:	PENOBSCOT
Business Address
Address 1:	491 MAIN STREET
Address 2:
City:	BANGOR
State:	ME
Zip:	04401
Phone:	207-947-7345
Fax:
Business Web Site Address:
Business Email Address:	LICENSING@CROSSAGENCY.COM
Mailing Address
Address 1:	PO BOX 1388
Address 2:
City:	BANGOR
State:	ME
Zip:	04402
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	YES	New DBA/Trade Name:	CROSS INSURANCE - PITTSFIELD
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:	ROYCE M. CROSS
Title:	PRESIDENT
Phone Number:	207-947-7345
Email Address:	LICENSING@CROSSAGENCY.COM