Notification of Changes for Business Entity
General Information
Business Entity Name:	EHEALTH INSURANCE SERVICES INC
Incorporation / Formation Date:
FEIN:	770470789
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	CA
County:	SANTA CLARA
Business Address
Address 1:	440 EAST MIDDLEFIELD RD
Address 2:
City:	MOUNTAIN VIEW
State:	CA
Zip:	94043
Phone:	9166086183
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	440 EAST MIDDLEFIELD RD
Address 2:
City:	MOUNTAIN VIEW
State:	CA
Zip:	94043
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
SHAUN HERMAN	AGENT	10919440	YES		01/04/2017
JORDAN LOYA	AGENT	18069040	YES		01/04/2017
JESSICA MARLEY	AGENT	18113643	YES		01/04/2017

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:	KARI EGEMO
Title:	LICENSING ADMINISTRATOR
Phone Number:	9166086183
Email Address:	LICENSING@EHEALTHINSURANCE.COM