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
JILLIAN BUCKLELEW	REGISTERED REP	17616307	YES		08/22/2017
TREVOR DARLEY	REGISTERED REP	18450892	YES		08/22/2017
JASON HABOUSH	REGISTERED REP	7469807	YES		08/22/2017
TREVOR RIX	REGISTERED REP	17133438	YES		08/22/2017
JARED ROCHE	REGISTERED REP	18475722	YES		08/22/2017
NATHANAEL THACHER	REGISTERED REP	18449560	YES		08/22/2017
BRADLEE WALTERS	REGISTERED REP	18471348	YES		08/22/2017

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:	FAITH HALE
Title:	LICENSE SPECIALIST II
Phone Number:	80004285708
Email Address:	FIDELITY@LICENSE-SUPPORT.COM