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
JAMES CHASE REGISTERED REP 8377801 YES   9/27/2017
HEIDI CLARKE REGISTERED REP 18454067 YES   9/27/2017
MELISSA LANNON REGISTERED REP 7413101 YES   9/27/2017
PETER MCGRATH REGISTERED REP 15204631 YES   9/27/2017
ANGELA MCNEILL REGISTERED REP 17374128 YES   9/27/2017
DAVE NEWSOME REGISTERED REP 18504642 YES   9/27/2017
LUCAS SEBBENS REGISTERED REP 18442624 YES   9/27/2017
           
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: KERRY TURNEY
Title: SR LICENSING SPECIALIST
Phone Number: 8004281324
Email Address: FIDELITY@LICENSE-SUPPORT.COM