DEPARTMENT OF INSURANCE

PUBLIC PROTECTION
CABINET

DEPARTMENT OF INSURANCE

Affiliations

Name	Evergreen Insurance Group	DOIID	1213149	NAIC NPN	20376510

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Inactive	Resident	Agent	Life	6/25/2022	3/31/2024
Inactive	Resident	Agent	Health	6/25/2022	3/31/2024
* If a status Is Pending, Pending Replacement,Or the record displays Affidavit On File, click On them For more details.

Appointments with the following Insurers

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Care Improvement Plus South Central Insurance Company	799697	Agent - Health	7/17/2022	9/16/2022
Inactive	UnitedHealthcare Insurance Company	300946	Agent - Health	7/9/2022	9/16/2022
Inactive	UnitedHealthcare Insurance Company of the River Valley	1027817	Agent - Health	7/9/2022	9/16/2022
Inactive	UnitedHealthcare of Wisconsin, Inc.	871491	Agent - Health	7/9/2022	9/16/2022

Designated Individuals

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Ford, Kim	944537	Agent - Health	6/25/2022	3/31/2024
Inactive	Ford, Kim	944537	Agent - Life	6/25/2022	3/31/2024