Notification of Changes for Business Entity
General Information
Business Entity Name:	HEALTH CHOICE ONE
Incorporation / Formation Date:	04282004
FEIN:	810648889
Ohio License Number:	31723
NPN:	8147241
DBA / Trade Name:
State of Domicile:	CO
County:	ARAPAHOE
Business Address
Address 1:	7951 E MAPLEWOOD AVE
Address 2:	SUITE 120
City:	GREENWOOD VILLAGE
State:	CO
Zip:	80111
Phone:	7202002825
Fax:	8667631086
Business Web Site Address:
Business Email Address:	JENNINE@GOHCO.COM
Mailing Address
Address 1:	7951 E. MAPLEWOOD AVE
Address 2:	SUITE 120
City:	GREENWOOD VILLAGE
State:	CO
Zip:	80111
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
AMANDA HUGHES	AGENT	17117391		YES	07-01-2017
ASHLEE LEMAY	AGENT	17523231		YES	07-01-2017
AUSTIN RIBLETT	AGENT	17427234		YES	07-01-2017
CARRIE CHIRO	AGENT	17418343		YES	07-01-2017
DELANA SMITH	AGENT	17420973		YES	07-01-2017
GEORGE ALLEN WAREJKO	AGENT	16401095		YES	07-01-2017
JARRED LYN GABLE	AGENT	17293578		YES	07-01-2017
JEREMY RYAN LYNCH	AGENT	17718501		YES	07-01-2017
JOSEPH MATTHEW BORBELY	AGENT	16185621		YES	07-01-2017
MARY ANN ELLIS	AGENT	7430113		YES	07-01-2017
PAUL DOUGLAS BORBELY	AGENT	16971505		YES	07-01-2017
RAHEEM J CLEMENTE	AGENT	17270298		YES	07-01-2017
RICKY ROBINSON	AGENT	17428076		YES	07-01-2017
SAMIR SALEH	AGENT	16950584		YES	07-01-2017
TASIA MONET ANDERSON	AGENT	17450067		YES	07-01-2017

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:	JENNINE SEEBACH
Title:	DIRECTOR OF AGENCY SERVICES
Phone Number:	720-200-2825
Email Address:	JENNINE@GOHCO.COM