Notification of Changes for Business Entity
General Information
Business Entity Name:	HEALTH CHOICE ONE INC
Incorporation / Formation Date:
FEIN:	810648889
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	CO
County:	ARAPAHOE
Business Address
Address 1:	6436 S RACINE CIR
Address 2:	STE 125
City:	CENTENNIAL
State:	CO
Zip:	80111
Phone:	720-200-2825 X131
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	6436 S RACINE CIR
Address 2:	STE 125
City:	CENTENNIAL
State:	CO
Zip:	80111
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
WALTERS, AMANDA M	PRODUCER	17524480	YES		04/12/2016
LEMAY, ASHLEE	PRODUCER	17523231	YES		04/12/2016
RIBLETT, AUSTIN	PRODUCER	17427234	YES		04/12/2016
CHIRO, CARRIE	PRODUCER	17418343	YES		04/12/2016
SUPPES, CHRISTOPHER	PRODUCER	17583907	YES		04/12/2016
GRANZEN, CHRISTOPHER WAYNE	PRODUCER	17521000	YES		04/12/2016
SMITH, DELANA	PRODUCER	17420973	YES		04/12/2016
LYNCH, JEREMY RYAN	PRODUCER	17718501	YES		04/12/2016
WATTS, JOSEPH HARRELL	PRODUCER	17716382	YES		04/12/2016
ADKERSON, JOY DARLENE	PRODUCER	10621121	YES		04/12/2016
ELLIS, MARY ANN	PRODUCER	7430113	YES		04/12/2016
POLING, MICHAEL C	PRODUCER	1713461	YES		04/12/2016
CLEMENTE, RAHEEM J	PRODUCER	17270298	YES		04/12/2016
ALEXANDER, REBECCA	PRODUCER	17407052	YES		04/12/2016
ROBINSON, RICKY	PRODUCER	17428076	YES		04/12/2016

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)	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:	DANIEL GARAVUSO
Title:	DIRECTOR, COMPLIANCE
Phone Number:	8133971493
Email Address:	DGARAVUSO@HIIQUOTE.COM