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
CHRISTOPHER PARRISH	PRODUCER	15085024	YES		11/28/2017
CLARISSA WILLIAMS	PRODUCER	17417802	YES		11/28/2017
CORY WEAVER	PRODUCER	9074016	YES		11/28/2017
DANIEL GROVE	PRODUCER	18403419	YES		11/28/2017
DAVID RICE	PRODUCER	1002229	YES		11/28/2017
DAVID LANGTRY	PRODUCER	18212714	YES		11/28/2017
DAVID JOSLYN	PRODUCER	18538101	YES		11/28/2017
DAVID PIAVIS	PRODUCER	2513302	YES		11/28/2017
DAVID THAMES	PRODUCER	17679272	YES		11/28/2017
DERRICK HENDERSON	PRODUCER	17070087	YES		11/28/2017
DONALD OATES	PRODUCER	1736422	YES		11/28/2017
EMILY MCINTIRE	PRODUCER	18464243	YES		11/28/2017
FELICIA SWALEH	PRODUCER	8099703	YES		11/28/2017
FRANK LAYTON IV	PRODUCER	17765708	YES		11/28/2017
FRANK LISKOVEC	PRODUCER	8814784	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