Notification of Changes for Business Entity
General Information
Business Entity Name:	RXHEALTH INSURANCE AGENCY INC
Incorporation / Formation Date:
FEIN:	26-2739398
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	CA
County:	LOS ANGELES
Business Address
Address 1:	600 WILSHIRE BLVD 11TH FLOOR
Address 2:
City:	LOS ANGELES
State:	CA
Zip:	90017
Phone:	800-379-0606
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	600 WILSHIRE BLVD 11TH FLOOR
Address 2:
City:	LOS ANGELES
State:	CA
Zip:	90017
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
JEREMY HAYS	AGENT	1080588		YES	04-13-2017

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:	KARI SMITH
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-886-0191
Email Address:	KNSMITH@SUPPORTIVEIS.COM