Notification of Changes for Business Entity
General Information
Business Entity Name:	EHEALTHINSURANCE SERVICES INC
Incorporation / Formation Date:
FEIN:	77-0470789
Ohio License Number:	100161292
NPN:	2971515
DBA / Trade Name:
State of Domicile:	CA
County:	SACRAMENTO
Business Address
Address 1:	11919 FOUNDATION PL #100
Address 2:
City:	GOLD RIVER
State:	CA
Zip:	95670
Phone:	916-608-6183
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	11919 FOUNDATION PL #100
Address 2:
City:	GOLD RIVER
State:	CA
Zip:	95670
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
KENNETH BROWN	IFP AGENT	17127669	YES		09.29.2016
TOMMY DEHOFF	IFP AGENT	7888207	YES		09.29.2016
RICHARD ROBERTS	IFP AGENT	8391190	YES		09.29.2016

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)	NO
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?	NO
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:	BARBARA CROSS
Title:	LICENSING
Phone Number:	916-608-6183
Email Address:	LICENSING@EHEALTHINSURANCE.COM