Notification of Changes for Business Entity
General Information
Business Entity Name:	HEALTHMARKETS INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	270277771-1
Ohio License Number:	39897
NPN:	14412207
DBA / Trade Name:	HEALTHMARKETS INSURANCE AGENCY
State of Domicile:	DE
County:	TARRANT
Business Address
Address 1:	9151 BOULEVARD 26
Address 2:
City:	NORTH RICHLAND HILLS
State:	TX
Zip:	76180
Phone:	817-255-3454
Fax:
Business Web Site Address:
Business Email Address:	ONBOARDING@HEALTHMARKETSHQ.COM
Mailing Address
Address 1:	9151 BOULEVARD 26
Address 2:
City:	NORTH RICHLAND HILLS
State:	TX
Zip:	76180
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
SARAH PEREZ	PRODUCER	16888673	YES		11/28/2017
SCOTT WODZAK	PRODUCER	18540989	YES		11/28/2017
SHARON WALTON	PRODUCER	17778425	YES		11/28/2017
STEVEN AMUNDSON	PRODUCER	7942472	YES		11/28/2017
STEVEN KUHN	PRODUCER	18527330	YES		11/28/2017
TAMARA DAUGHTERY	PRODUCER	15952780	YES		11/28/2017
THELMA MOULTRIE	PRODUCER	6824114	YES		11/28/2017
TIKA DHUNGANA	PRODUCER	17424048	YES		11/28/2017
TINA OLEXO	PRODUCER	18010168	YES		11/28/2017
WILLIAM JONES	PRODUCER	17685399	YES		11/28/2017
WINDELL WALTERS	PRODUCER	17624644	YES		11/28/2017
WISSAM HADBA	PRODUCER	17878904	YES		11/28/2017
YVETTE WILKINS	PRODUCER	11907881	YES		11/28/2017

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:	JAMES C MASON
Title:	SR VICE PRESIDENT
Phone Number:	817-255-3454
Email Address:	ONBOARDING@HEALTHMARKETSHQ.COM