Notification of Changes for Business Entity
General Information  
Business Entity Name: CAREZONE FINANCIAL SERVICES LLC
Incorporation / Formation Date:  
FEIN: 30-0882838
Ohio License Number:
NPN: 17745245
DBA / Trade Name:  
State of Domicile: DE
County: NEWCASTLE
Business Address  
Address 1: 3175 17TH STREET
Address 2:  
City: SAN FRANCISCO
State: CA
Zip: 94110
Phone: (916) 237-0162
Fax:  
Business Web Site Address:  
Business Email Address:  
Mailing Address  
Address 1: 3175 17TH STREET
Address 2:  
City: SAN FRANCISCO
State: CA
Zip: 94110
   
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
KIRT DALEBOUT MEDICARE SALES AGENT 17334096 YES   08/25/2016
JAMES JONES MEDICARE SALES AGENT 17302306 YES   08/25/2016
NICOLE WHITTEN MEDICARE SALES AGENT 17277516 YES   08/25/2016
RICHARD WALDO MEDICARE SALES AGENT 17446089 YES   08/25/2016
           
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)
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: DAVID SULLIVAN
Title: GENERAL MANAGER
Phone Number: (916) 237-0162
Email Address: DSULLIVAN@CAREZONE.COM