Notification of Changes for Business Entity
General Information
Business Entity Name:	EHEALTHINSURANCE SERVICES, INC.
Incorporation / Formation Date:
FEIN:	77-0470789
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	SACRAMENTO, CA
Business Address
Address 1:	11919 FOUNDATION PLACE
Address 2:	SUITE 100
City:	GOLD RIVER
State:	CA
Zip:	95670
Phone:	916-608-6165
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	11919 FOUNDATION PLACE
Address 2:	SUITE 100
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
A. BROOME-HOPKINS	PRODUCER / AGENT	1129808	YES		05/30/2017
R. CARUSO	PRODUCER / AGENT	1149763	YES		05/30/2017

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)	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:	BRITTANY JACKSON
Title:	LICENSING ASSISTANT
Phone Number:	916-608-6165
Email Address:	LICENSING@EHEALTHINSURANCE.COM