| Notification of Changes for Business Entity |
| General Information | |
| Business Entity Name: | HUMANA MARKETPOINT AGENCY |
| Incorporation / Formation Date: | |
| FEIN: | 611343508 |
| Ohio License Number: | 24204 |
| NPN: | |
| DBA / Trade Name: | |
| State of Domicile: | KY |
| County: | JEFFERSON |
| Business Address | |
| Address 1: | 500 WEST MAIN STREET |
| Address 2: | |
| City: | LOUISVILLE |
| State: | KY |
| Zip: | 40202 |
| Phone: | 502-580-1000 |
| Fax: | |
| Business Web Site Address: | |
| Business Email Address: | |
| Mailing Address | |
| Address 1: | 500 WEST MAIN STREET |
| Address 2: | |
| City: | LOUISVILLE |
| State: | KY |
| Zip: | 40202 |
| | |
| 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 |
| BELL, MS. SHARON | AGENT | 18538205 | YES | | 11/03/2017 |
| BENAVIDES, MR. JOSHUA ADAM | AGENT | 8027310 | YES | | 11/03/2017 |
| BERKHEIMER, MR. ZACHARY DAVID | AGENT | 18026722 | YES | | 11/03/2017 |
| BERNAL, MS. DEBRA | AGENT | 4041537 | YES | | 11/03/2017 |
| BERTRAND, MS. JEAN | AGENT | 7840818 | YES | | 11/03/2017 |
| BEST, MR. SHAMON A. | AGENT | 18512221 | YES | | 11/03/2017 |
| BESTER JR, MR. ROBERT MICHAEL | AGENT | 16287395 | | YES | 11/03/2017 |
| BHAT, MR. GIRISH VENKATARAMAN | AGENT | 18471038 | YES | | 11/03/2017 |
| BISHOP, MR. WINSTON B | AGENT | 18496517 | YES | | 11/03/2017 |
| BLACKMON, MR. BRANDON KRISTOPH | AGENT | 17663947 | YES | | 11/03/2017 |
| BLEVINS, MR. RICHARD GLENN (RI | AGENT | 548676 | YES | | 11/03/2017 |
| BLYTHE, MS. SABRINA L | AGENT | 1467873 | | YES | 11/03/2017 |
| BOBADILLA, MS. ANEL PRISCILLA | AGENT | 17679975 | YES | | 11/03/2017 |
| BOBO, MS. LOTOYA | AGENT | 9746948 | | YES | 11/03/2017 |
| BOLEN, MR. RYAN W. | AGENT | 17029342 | | YES | 11/03/2017 |
| | | | | | |
| 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 | |