Notification of Changes for Business Entity
General Information
Business Entity Name:	HGS COLIBRIUM INC.
Incorporation / Formation Date:
FEIN:	47-2873786
Ohio License Number:	1077015
NPN:	17676388
DBA / Trade Name:
State of Domicile:	GA
County:	FULTON
Business Address
Address 1:	1805 OLD ALABAMA ROAD SUITE 220
Address 2:
City:	ROSWELL
State:	GA
Zip:	30076
Phone:	855-215-4559
Fax:
Business Web Site Address:
Business Email Address:	DEBORAH.CRIMS@TEAMHGS.COM
Mailing Address
Address 1:	1805 OLD ALABAMA ROAD SUITE 220
Address 2:
City:	ROSWELL
State:	GA
Zip:	30076
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
PAMELA HAMMOND	LICENSED SALES AGENT	3901918	YES		6/13/2018
MICHAEL HAMMOND	LICENSED SALES AGENT	13298560	YES		6/13/2018
DANIEL HIGHTOWER	LICENSED SALES AGENT	17244405	YES		6/13/2018
HAORAN LU	LICENSED SALES AGENT	17976002	YES		6/13/2018
CHRIS LYNCH	LICENSED SALES AGENT	7708165	YES		6/13/2018
YUVAL MANO	LICENSED SALES AGENT	17498031	YES		6/13/2018
DAVID MCGUIRE	LICENSED SALES AGENT	9792826	YES		6/13/2018
ERICA MEDINA	LICENSED SALES AGENT	8333431	YES		6/13/2018
SILVIA MEDINA	LICENSED SALES AGENT	8890164	YES		6/13/2018
TUNISIA MELTON	LICENSED SALES AGENT	18562693	YES		6/13/2018
RAUL MIRELES	LICENSED SALES AGENT	8682501	YES		6/13/2018
KENNETH MORING	LICENSED SALES AGENT	18348709	YES		6/13/2018
KELLY NUCKOLLS	LICENSED SALES AGENT	13854107	YES		6/13/2018
JORGE OCAMPO	LICENSED SALES AGENT	17492042	YES		6/13/2018
PRIYADARSHANI RANA	LICENSED SALES AGENT	18380827	YES		6/13/2018

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:	SHARON BOONE
Title:	OPERATIONS DIRECTOR
Phone Number:	7703294521
Email Address:	SHARON.BOONE@TEAMHGS.COM