DEPARTMENT OF INSURANCE

Affiliations

Name	Forman, William Stanton	DOIID	764147	NAIC NPN	16397009

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date
Inactive	Resident	Agent	Property	10/4/2011	9/1/2016
Inactive	Resident	Agent	Casualty	7/17/2012	9/1/2016
* If a status Is Pending, Pending Replacement,Or the record displays Affidavit On File, click On them For more details.

Appointments with the following Insurers

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	1st Choice Advantage Insurance Company, Inc.	750782	Agent - Casualty	11/1/2012	11/1/2015
Inactive	ACUITY, A Mutual Insurance Company	300095	Agent - Casualty	8/28/2012	6/11/2015
Inactive	ACUITY, A Mutual Insurance Company	300095	Agent - Property	8/28/2012	6/11/2015
Inactive	Allied Eastern Indemnity Company	683842	Agent - Casualty	3/6/2013	1/6/2016
Inactive	American Fire and Casualty Company	300567	Agent - Casualty	4/3/2013	9/28/2015
Inactive	American Fire and Casualty Company	300567	Agent - Property	4/3/2013	9/28/2015
Inactive	Association Casualty Insurance Company	650779	Agent - Casualty	9/1/2013	9/1/2016
Inactive	Association Casualty Insurance Company	650779	Agent - Property	9/1/2013	9/1/2016
Inactive	Bristol West Insurance Company	301655	Agent - Casualty	3/26/2013	9/1/2016
Inactive	Bristol West Insurance Company	301655	Agent - Property	3/26/2013	9/1/2016
Inactive	Cincinnati Casualty Company (The)	300308	Agent - Casualty	7/31/2012	6/30/2015
Inactive	Cincinnati Casualty Company (The)	300308	Agent - Property	7/31/2012	6/30/2015
Inactive	Cincinnati Indemnity Company (The)	301566	Agent - Casualty	7/31/2012	6/30/2015
Inactive	Cincinnati Indemnity Company (The)	301566	Agent - Property	7/31/2012	6/30/2015
Inactive	Cincinnati Insurance Company	301298	Agent - Casualty	7/31/2012	6/30/2015
Inactive	Cincinnati Insurance Company	301298	Agent - Property	7/31/2012	6/30/2015
Inactive	Columbia Mutual Insurance Company	301295	Agent - Casualty	9/1/2013	9/1/2016
Inactive	Columbia Mutual Insurance Company	301295	Agent - Property	9/1/2013	9/1/2016
Inactive	Consolidated Insurance Company	300943	Agent - Casualty	4/3/2013	9/28/2015
Inactive	Consolidated Insurance Company	300943	Agent - Property	4/3/2013	9/28/2015
Inactive	Eastern Advantage Assurance Company	692390	Agent - Casualty	3/6/2013	1/6/2016
Inactive	Eastern Alliance Insurance Company	683841	Agent - Casualty	3/6/2013	1/6/2016
Inactive	Everett Cash Mutual Insurance Company	750768	Agent - Casualty	11/1/2012	11/1/2015
Inactive	Everett Cash Mutual Insurance Company	750768	Agent - Property	11/1/2012	11/1/2015
Inactive	FCCI Insurance Company	557454	Agent - Casualty	1/24/2013	12/17/2015
Inactive	FCCI Insurance Company	557454	Agent - Property	1/24/2013	12/17/2015
Inactive	Foremost Insurance Company Grand Rapids, Michigan	301027	Agent - Casualty	3/26/2013	9/1/2016
Inactive	Foremost Insurance Company Grand Rapids, Michigan	301027	Agent - Property	3/26/2013	9/1/2016
Inactive	Hartford Insurance Company of the Midwest	301918	Agent - Casualty	4/24/2013	12/17/2014
Inactive	Hartford Insurance Company of the Midwest	301918	Agent - Property	4/24/2013	12/17/2014
Inactive	Indiana Insurance Company	301909	Agent - Casualty	4/3/2013	9/28/2015
Inactive	Indiana Insurance Company	301909	Agent - Property	4/3/2013	9/28/2015
Inactive	National Trust Insurance Company	300367	Agent - Casualty	1/24/2013	12/17/2015
Inactive	National Trust Insurance Company	300367	Agent - Property	1/24/2013	12/17/2015
Inactive	Netherlands Insurance Company (The)	300339	Agent - Casualty	4/3/2013	9/28/2015
Inactive	Netherlands Insurance Company (The)	300339	Agent - Property	4/3/2013	9/28/2015
Inactive	Ohio Casualty Insurance Company	301492	Agent - Casualty	4/1/2013	9/28/2015
Inactive	Ohio Casualty Insurance Company	301492	Agent - Property	4/3/2013	9/28/2015
Inactive	Ohio Security Insurance Company	300622	Agent - Casualty	4/3/2013	9/28/2015
Inactive	Ohio Security Insurance Company	300622	Agent - Property	4/3/2013	9/28/2015
Inactive	Peerless Indemnity Insurance Company	571682	Agent - Casualty	4/3/2013	9/28/2015
Inactive	Peerless Indemnity Insurance Company	571682	Agent - Property	4/3/2013	9/28/2015
Inactive	Peerless Insurance Company	301910	Agent - Casualty	4/3/2013	9/28/2015
Inactive	Peerless Insurance Company	301910	Agent - Property	4/3/2013	9/28/2015
Inactive	Philadelphia Indemnity Insurance Company	301221	Agent - Casualty	4/24/2013	9/1/2016
Inactive	Philadelphia Indemnity Insurance Company	301221	Agent - Property	4/24/2013	9/1/2016
Inactive	SAFECO Insurance Company of America	300159	Agent - Casualty	4/3/2013	9/28/2015
Inactive	SAFECO Insurance Company of America	300159	Agent - Property	4/3/2013	9/28/2015
Inactive	SAFECO Insurance Company of Illinois	301350	Agent - Casualty	4/3/2013	9/28/2015
Inactive	SAFECO Insurance Company of Illinois	301350	Agent - Property	4/3/2013	9/28/2015
Inactive	West American Insurance Company	301112	Agent - Casualty	4/3/2013	9/28/2015
Inactive	West American Insurance Company	301112	Agent - Property	4/3/2013	9/28/2015

Designated to act on behalf of the following Business Entities

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Peel & Holland Inc	398400	Agent - Casualty	7/31/2012	6/30/2015
Inactive	Peel & Holland Inc	398400	Agent - Property	7/31/2012	6/30/2015