Notification of Changes for Business Entity
General Information  
Business Entity Name: EHEALTHINSURANCE SERVICES, INC.
Incorporation / Formation Date:  
FEIN: 770470789
Ohio License Number:
NPN:
DBA / Trade Name:  
State of Domicile: CA
County: SACRAMENTO
Business Address  
Address 1: 11919 FOUNDATION PL #100
Address 2:  
City: GOLD RIVER
State: CA
Zip: 95670
Phone: 916-608-6183
Fax:  
Business Web Site Address:  
Business Email Address: LICENSING@EHEALTHINSURANCE.COM
Mailing Address  
Address 1: 11919 FOUNDATION PL #100
Address 2:  
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
MOHAMMAD KHAN AGENT 17857552   YES 02/09/2017
LISA GIANATASIO AGENT 3407040   YES 02/09/2017
TRACEY LATHAM AGENT 9591230   YES 02/09/2017
JUAN MALDONADO AGENT 16978204   YES 02/09/2017
BRIAN WAGNER AGENT 17446081   YES 02/09/2017
NAVISH REDDY AGENT 18187436   YES 02/09/2017
WILLIAM DOUGHERTY AGENT 18170151   YES 02/09/2017
           
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) 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: BARBARA CROSS
Title: LICENSING ASSISTANT
Phone Number: 916-608-6183
Email Address: LICENSING@EHEALTHINSURANCE.COM