Notification of Changes for Business Entity
General Information
Business Entity Name:	EHEALTH INSURANCE
Incorporation / Formation Date:
FEIN:	77-0470789
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	CA
County:	SACRAMENTO
Business Address
Address 1:	11919 FOUNDATION PLACE, SUITE 100
Address 2:
City:	GOLD RIVER
State:	CA
Zip:	95670
Phone:	916-608-6183
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	11919 FOUNDATION PLACE, SUITE 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
EMMELINA BALES	MAJOR LINES	18796102	YES		05/31/2018
JASON RICHARD BLEVINS	MAJOR LINES	18134488	YES		05/31/2018
BRYAN BURTON	MAJOR LINES	18796116	YES		05/31/2018
DAWN DAWDY-MOORE	MAJOR LINES	18796092	YES		05/31/2018
SALIMA DHANANI	MAJOR LINES	18796188	YES		05/31/2018
JENNIFER A DORNBUSCH	MAJOR LINES	18775508	YES		05/31/2018
BRIEANA LANEE DREW	MAJOR LINES	18772606	YES		05/31/2018
KATHLEEN J EMBRY	MAJOR LINES	1258584	YES		05/31/2018
JORGE DE JESUS ESQUER	MAJOR LINES	18779417	YES		05/31/2018
SHONTINIQUA SONYELL FREEMAN	MAJOR LINES	18772615	YES		05/31/2018
AARON GALLEGOS	MAJOR LINES	18772647	YES		05/31/2018
AUSTIN GREGORY HOUSER	MAJOR LINES	17729458	YES		05/31/2018
ANGELA KAY JOHNSON	MAJOR LINES	18796128	YES		05/31/2018
NORIE TISHAYE MACKEY-STEELE	MAJOR LINES	18794725	YES		05/31/2018
JERRY EDWARD MENDL	MAJOR LINES	18796070	YES		05/31/2018

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)
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:	ESTY NGUYEN
Title:	LICENSING ASSISTANT
Phone Number:	801-562-4051
Email Address:	LICENSING@EHEALTHINSURANCE.COM