Notification of Changes for Business Entity
General Information
Business Entity Name:	EHEALTHINSURANCE SERVICES, INC
Incorporation / Formation Date:
FEIN:	77-0470789
Ohio License Number:	25097
NPN:	2971515
DBA / Trade Name:
State of Domicile:	CA
County:	SACRAMENTO
Business Address
Address 1:	11919 FOUNDATION PLACE
Address 2:	STE 100
City:	GOLD RIVER
State:	CA
Zip:	95670
Phone:	800-299-3116
Fax:	916-608-4696
Business Web Site Address:
Business Email Address:	LICENSING@EHEALTHINSURANCE.COM
Mailing Address
Address 1:	11919 FOUNDATION PLACE
Address 2:	STE 100
City:	GOLD RIVER
State:	CA
Zip:	95670
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
BROWN, JACQUELINE	MSR	1075332	YES		09-29-2016
CARBO, JOSEPH	MSR	1120400	YES		09-29-2016
CLARK, KENNETH	MSR	1075311	YES		09-29-2016
COOPER, VALERIE	MSR	1074193	YES		09-29-2016
DEBBAUDT, ALBA	MSR	1120407	YES		09-29-2016
EDWARDS, MILDRED	MSR	1120414	YES		09-29-2016
FERGUSON, LESLEY	MSR	1003843	YES		09-29-2016
GILLIS, PLEASURE	MSR	1123617	YES		09-29-2016
GRAY, ARLENE	MSR	1120424	YES		09-29-2016
GREEN, CASSIE	MSR	940746	YES		09-29-2016
HAWKINS, ALEX	MSR	1121304	YES		09-29-2016
HAYMES, DWENDOLYN	MSR	1013075	YES		09-29-2016
HOWARD, LLOYD	MSR	1005925	YES		09-29-2016
JACKSON, ANNEMARIE	MSR	1120427	YES		09-29-2016
JOHNSON, YASMIN	MSR	1080564	YES		09-29-2016

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:	SUZANNE CHRISTENSEN
Title:	LICENSING
Phone Number:	801-562-4018
Email Address:	LICENSING@EHEALTHINSURANCE.COM