Notification of Changes for Business Entity
General Information
Business Entity Name:	HP AGENCY, INC
Incorporation / Formation Date:	10/13/1994
FEIN:	34-1764520
Ohio License Number:	OH 4729
NPN:	1883247
DBA / Trade Name:
State of Domicile:	OH
County:	BELMONT
Business Address
Address 1:	52160 NATIONAL RD. EAST
Address 2:
City:	ST. CLAIRSVILLE
State:	OH
Zip:	43950
Phone:	740-695-3585
Fax:
Business Web Site Address:	HEALTHPLAN.ORG
Business Email Address:	CMAMONE@HEALTHPLAN.ORG
Mailing Address
Address 1:	52160 NATIONAL RD. EAST
Address 2:
City:	ST. CLAIRSVILLE
State:	OH
Zip:	43950
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	CAROL MAMONE - PREVIOUS CONTACT INFO-JAN WHORTON
Title:	SALES COORDINATOR
Phone Number:	740-699-6249
Email Address:	CMAMONE@HEALTHPLAN.ORG - CHANGE IS CONTACT INFO