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:	HEALTHMARKETS INSURANCE AGENCY
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
JERALD SKARNULIS	PRODUCER	13374569	YES		02/20/2018
JILL SHEPARD	PRODUCER	18142208	YES		02/20/2018
JOHNNY PINEDA	PRODUCER	9205799	YES		02/20/2018
JUVINA SUBLETT	PRODUCER	9911940	YES		02/20/2018
LAWRENCE YI	PRODUCER	16992296	YES		02/20/2018
MARGARET HAMMOND	PRODUCER	7815088	YES		02/20/2018
MARISA BLOOM	PRODUCER	16196010	YES		02/20/2018
MARSHALL GUILMETTE	PRODUCER	18229868	YES		02/20/2018
MARYANN MLODZIK	PRODUCER	18355789	YES		02/20/2018
PATRICE MARTIN	PRODUCER	17697439	YES		02/20/2018
PATRICIA OYEGOKE	PRODUCER	17095478	YES		02/20/2018
PAUL LINDGREN	PRODUCER	656922	YES		02/20/2018
RONALD CERRITELLI	PRODUCER	512463	YES		02/20/2018
SHANNON KOCHENSPARGER	PRODUCER	18600113	YES		02/20/2018
SOMSANOUK SOUIMANIPHANH	PRODUCER	17537556	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