Notification of Changes for Business Entity
General Information
Business Entity Name:	STARKWEATHER & SHEPLEY INS. BROKERAGE INC.
Incorporation / Formation Date:
FEIN:	050222530
Ohio License Number:	37378
NPN:	765177
DBA / Trade Name:
State of Domicile:	RI
County:	PROVIDENCE
Business Address
Address 1:	60 CATAMORE BLVD
Address 2:
City:	EAST PROVIDENCE
State:	RI
Zip:	02914
Phone:	4014353600
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	PO BOX 549
Address 2:
City:	PROVIDENCE
State:	RI
Zip:	02901
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DAVID SOFORENKO	PRESIDENT & COO	037-40-0920		YES	01/01/2018
AMY GULDHAUGE	TREASURER	039-46-2675	YES		01/01/2018

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:	JILL HULME
Title:	LICENSING TECHNICIAN
Phone Number:	4014353600
Email Address:	JHULME@STARSHEP.COM