Notification of Changes for Business Entity
General Information
Business Entity Name:	EVOLENT HEALTH LLC
Incorporation / Formation Date:
FEIN:	45-3084136
Ohio License Number:	1072552
NPN:	16822008
DBA / Trade Name:
State of Domicile:	VA
County:	ARLINGTON
Business Address
Address 1:	800 N. GLEBE RD, SUITE 500
Address 2:
City:	ARLINGTON
State:	VA
Zip:	22203
Phone:	571-385-2070
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	800 N. GLEBE RD, SUITE 500
Address 2:
City:	ARLINGTON
State:	VA
Zip:	22203
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
TANISHA WOODARD	DESIGNATED PRODUCER	8615704		YES	12/1/17
TONY BRICE	DESIGNATED PRODUCER	1466167		YES	12/1/17

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:	JONATHAN WEINBERG
Title:	GENERAL COUNSEL, SECRETARY
Phone Number:	571-385-2070
Email Address:	CTREGOE@EVOLENTHEALTH.COM