Notification of Changes for Business Entity
General Information
Business Entity Name:	HEALTH IQ INS SERVICES
Incorporation / Formation Date:	05/20/2015
FEIN:	47-4066842
Ohio License Number:	1069800
NPN:	17603304
DBA / Trade Name:
State of Domicile:	DE
County:	US
Business Address
Address 1:	2513 CHALRESTON RD STE 102
Address 2:
City:	MOUNTAIN VIEW
State:	CA
Zip:	94043
Phone:	6503861252
Fax:	6504690250
Business Web Site Address:
Business Email Address:	AGENT-LICENSING@HEALTHIQ.COM
Mailing Address
Address 1:	SAME AS ABOVE
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
MARTIN HECHT	PRODUCER	16412355	YES		05/11/2017
MARIO JIMENEZ	PRODUCER	18396002	YES		05/11/2017

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:	HAILEY OVERBY
Title:	TREAS OF KLS
Phone Number:	2148550737
Email Address:	HOVERBY@KENNEDYLICENSING.COM