Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
NPN:	8415824
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
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
RIVERA, IRVING	BENEFIT ADVISOR	10390416	YES		12/31/15
ROBERSON, BRIAN	BENEFIT ADVISOR	7125474	YES		12/31/15
ROBERTSON, JIDA	BENEFIT ADVISOR	17595563	YES		12/31/15
ROBINS, TODD	BENEFIT ADVISOR	9262191	YES		12/31/15
ROBINSON, CHERISH	BENEFIT ADVISOR	17673905	YES		12/31/15
ROBINSON, JOSHUA	BENEFIT ADVISOR	17685895	YES		12/31/15
ROBISON, IRINA	BENEFIT ADVISOR	15946826	YES		12/31/15
RODGERS, ALLYN	BENEFIT ADVISOR	17589030	YES		12/31/15
RODGERS, GREGORY	BENEFIT ADVISOR	17673838	YES		12/31/15
RODRIGUEZ, ANGELIQUE	BENEFIT ADVISOR	14448760	YES		12/31/15
RODRIGUEZ, GRACIE	BENEFIT ADVISOR	17597857	YES		12/31/15
ROGERS, DAVID	BENEFIT ADVISOR	16264687	YES		12/31/15
ROGERS, JAMES	BENEFIT ADVISOR	17085484	YES		12/31/15
ROOT, DAVID	BENEFIT ADVISOR	1108904	YES		12/31/15
ROSS, CHRISTINE	BENEFIT ADVISOR	17417354	YES		12/31/15

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:	CAMERON LILJENQUIST
Title:	SVP AND CHIEF TECHNOLOGY OFFICER
Phone Number:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM