Notification of Changes for Business Entity
General Information
Business Entity Name:	HEALTHMARKETS INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	27-027777-1
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@HELATHMARKETSHQ.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
GEORGE MILLER	PRODUCER	1124006	YES		11/28/2017
GREGORY DRAKE	PRODUCER	8422758	YES		11/28/2017
HARMONI SAUDER	PRODUCER	17749888	YES		11/28/2017
JAMES DOWNEY	PRODUCER	17676594	YES		11/28/2017
JAMES WILLITS	PRODUCER	8433524	YES		11/28/2017
JANE BARONE	PRODUCER	18495257	YES		11/28/2017
JARED VAN DYKE	PRODUCER	2096696	YES		11/28/2017
JEFFREY DANULOFF	PRODUCER	15608553	YES		11/28/2017
JENNIFER HAGER	PRODUCER	17060477	YES		11/28/2017
JOHN HEIGHWAY	PRODUCER	1735507	YES		11/28/2017
JOSEPH THOMAS	PRODUCER	17881813	YES		11/28/2017
KAHLIL MANNING	PRODUCER	15653093	YES		11/28/2017
LATRISHIA SMITH	PRODUCER	17673917	YES		11/28/2017
LAURA WINNINGHAM	PRODUCER	13367820	YES		11/28/2017
LISA RODRIGUEZ	PRODUCER	18493539	YES		11/28/2017

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:	JAMES C MASON
Title:	SR VICE PRESIDENT
Phone Number:	817-255-3454
Email Address:	ONBOARDING@HEALTHMARKETSHQ.COM