DEPARTMENT OF INSURANCE

PUBLIC PROTECTION
CABINET

DEPARTMENT OF INSURANCE

Affiliations

Name	Poisson, Nichole Lorraine	DOIID	616832	NAIC NPN	8151416

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Inactive	Non Resident	Agent	Casualty	9/26/2005	10/27/2015
Inactive	Non Resident	Agent	Property	9/26/2005	10/27/2015
Inactive	Non Resident	Surplus Lines Broker	Not Applicable	8/11/2014	10/27/2015
* 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	Evergreen USA Risk Retention Group, Inc.	503256	Agent - Casualty	9/26/2005	10/27/2015
Inactive	Evergreen USA Risk Retention Group, Inc.	503256	Agent - Property	9/26/2005	10/27/2015

Designated to act on behalf of the following Business Entities

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Leavitt Recreation & Hospitality Ins Inc	660397	Agent - Casualty	6/10/2014	2/17/2015
Inactive	Leavitt Recreation & Hospitality Ins Inc	660397	Agent - Property	6/10/2014	2/18/2015
Inactive	Leavitt Recreation & Hospitality Ins Inc	660397	Surplus Lines Broker - Not Applicable	2/12/2015	2/18/2015