Notification of Changes for Business Entity
General Information  
Business Entity Name: RXHEALTH INS AGENCY INC
Incorporation / Formation Date:  
FEIN: 262739398
Ohio License Number: 38209
NPN:
DBA / Trade Name:  
State of Domicile: OH
County: LOS ANGELES
Business Address  
Address 1: 600 WILSHIRE BLVD 11TH FLOOR
Address 2:  
City: LOS ANGELES
State: CA
Zip: 90017
Phone: 800 379 0606
Fax: 4356493245
Business Web Site Address:  
Business Email Address:  
Mailing Address  
Address 1: 600 WHILSHIRE BLVD 11TH FLOOR
Address 2:  
City: LOS ANGELES
State: OH
Zip: 90017
   
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
JEFFERY SURGES CEO 356709185 YES   01/03/2018
JEFFERY SURGES PRESIDENT 356709185 YES   01/03/2018
JEFFERY SURGES DIRECTOR 356709185 YES   01/03/2018
VINCENT ESTRADA CFO 337547099 YES   01/03/2018
RYAN MULLIGAN DIRECTOR OF SALES 237597131 YES   01/03/2018
MICHAEL CHO VICE PRESIDENT 237597131   YES 01/03/2018
VICKI CAPPS DIRECTOR 565237889   YES 01/03/2018
           
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: CHRISTY KRICK
Title: LICENSING ADMINISTRATOR
Phone Number: 8124942472
Email Address: CKRICK@SUPPORTIVEIS.COM