Notification of Changes for Business Entity
General Information
Business Entity Name:	FIDELITY INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	042710779
Ohio License Number:	28850
NPN:	654103
DBA / Trade Name:
State of Domicile:	MA
County:	SUFFOLK
Business Address
Address 1:	200 SEAPORT BLVD V2A
Address 2:
City:	BOSTON
State:	MA
Zip:	02210
Phone:	617-563-1175
Fax:
Business Web Site Address:
Business Email Address:	FIDELITY@LICENSE-SUPPORT.COM
Mailing Address
Address 1:	ATTN: KATHERINE HUTCHINSON
Address 2:	MAILZONE WA1M
City:	WESTLAKE
State:	TX
Zip:	76262
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:	SHERRI MILLER
Title:	SR LRS SPECIALIST
Phone Number:	8004285708
Email Address:	FIDELITY@LICENSE-SUPPORT.COM