Notification of Changes for Business Entity
General Information
Business Entity Name:	HEALTH CHOICE ONE
Incorporation / Formation Date:	04282004
FEIN:	810648889
Ohio License Number:	31723
NPN:	8147241
DBA / Trade Name:
State of Domicile:	CO
County:	ARAPAHOE
Business Address
Address 1:	7951 E. MAPLEWOOD AVE
Address 2:	SUITE 120
City:	GREENWOOD VILLAGE
State:	CO
Zip:	80111
Phone:	720-200-2825
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	7951 E. MAPLEWOOD AVE
Address 2:	SUITE 120
City:	GREENWOOD VILLAGE
State:	CO
Zip:	80111
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
JANELLE LOVATO	AGENT	17255722		YES	07-01-2017

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)
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:	JENNINE SEEBACH
Title:	DIRECTOR OF AGENCY SERIVCES
Phone Number:	720-200-2825
Email Address:	JENNINE@GOHCO.COM