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:
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
AARON BOLTON	PRODUCER	18377938		YES	02/20/2018
ARLENE YOUNG	PRODUCER	12220148		YES	02/20/2018
BRANDON HOLT	PRODUCER	15684392		YES	02/20/2018
CARL JENSEN	PRODUCER	2263699		YES	02/20/2018
CHAD COLSTON	PRODUCER	2190584		YES	02/20/2018
DANIEL SURCKLA	PRODUCER	1846545		YES	02/20/2018
DAVID RICE	PRODUCER	1002229		YES	02/20/2018
DAVID LANGTRY	PRODUCER	18212714		YES	02/20/2018
DONNA FISCHER	PRODUCER	9154309		YES	02/20/2018
EMILY MCINTIRE	PRODUCER	1161033		YES	02/20/2018
GEORGE MILLER	PRODUCER	1124006		YES	02/20/2018
GILBERT PRITCHETT	PRODUCER	17925954		YES	02/20/2018
KENNETH HARRISON	PRODUCER	8855445		YES	02/20/2018
LATRISHIA SMITH	PRODUCER	17673917		YES	02/20/2018
MARIE HOLLWEDEL	PRODUCER	9777022		YES	02/20/2018

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