Notification of Changes for Business Entity
General Information
Business Entity Name:	HEALTH IQ INSURANCE SERVICES INC.
Incorporation / Formation Date:	05/20/2015
FEIN:	474066842
Ohio License Number:	1069800
NPN:	17603304
DBA / Trade Name:
State of Domicile:	CA
County:	US
Business Address
Address 1:	2513 CHARLESTON RD STE 102
Address 2:
City:	MOUNTAIN VIEW
State:	CA
Zip:	94043
Phone:	6503861252
Fax:	6504690250
Business Web Site Address:
Business Email Address:	AGENT-LICENSING@HEALTHIQ.COM
Mailing Address
Address 1:	2513 CHARLESTON RD STE 102
Address 2:
City:	MOUNTAIN VIEW
State:	CA
Zip:	94043
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
CONNOR COSGROVE	AGENT	1207787	YES		09/12/2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
GAURAV SURI

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:	GAURAV SURI
Title:	SEC
Phone Number:	6503861252
Email Address:	AGENT-LICENSING@HEALTHIQ.COM