Notification of Changes for Business Entity
General Information
Business Entity Name:	HGS COLIBIRUM
Incorporation / Formation Date:	08/15/2015
FEIN:	472873786
Ohio License Number:	1077015
NPN:	17676388
DBA / Trade Name:
State of Domicile:	GA
County:	FULTON
Business Address
Address 1:	1805 OLD ALABAMA ROAD
Address 2:	SUITE 220
City:	ROSWELL
State:	GA
Zip:	30076
Phone:	8552154559
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1805 OLD ALABAMA ROAD
Address 2:	SUITE 220
City:	ROSWELL
State:	GA
Zip:	30076
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
SHARON BOONE	DIRECTOR	8111033		YES	09/12/18
RIYADARSHANI RANA	AGENT	18380827		YES	0912/18

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:	DEBORAH CRIMS
Title:	LICENSING COORDINATOR
Phone Number:	855-215-4559
Email Address:	DEBORAH.CRIMS@TEAMHGS.COM