Notification of Changes for Business Entity
General Information
Business Entity Name:	RXHEALTH INS AGENCY INC
Incorporation / Formation Date:
FEIN:	262739398
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	WI
County:	WAUKESHA
Business Address
Address 1:	18500 W CORPORATE STE 250
Address 2:
City:	BROOKFIELD
State:	WI
Zip:	53045
Phone:	800-379-0606
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	18500 W CORPORATE STE 250
Address 2:
City:	BROOKFIELD
State:	WI
Zip:	53045
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
MICHAEL CHO	AGENY	12862361		YES	03-01-2018

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)
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