Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCHANGE INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
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
FLANAGAN, SEAN	BENEFIT ADVISOR	17446385	YES		12/30/15
FLORES, DONNA	BENEFIT ADVISOR	17365444	YES		12/30/15
FORBES, AMANDA	BENEFIT ADVISOR	16111190	YES		12/30/15
FORSTER, JOHN	BENEFIT ADVISOR	17608406	YES		12/30/15
FORTNEY, MARY	BENEFIT ADVISOR	17378511	YES		12/30/15
FOSTER, SATAURUS	BENEFIT ADVISOR	17658235	YES		12/30/15
FOWLER, AMY	BENEFIT ADVISOR	17071126	YES		12/30/15
FOWLER, EDWARD	BENEFIT ADVISOR	5458049	YES		12/30/15
FRAIRE, CRISTOBAL	BENEFIT ADVISOR	17034948	YES		12/30/15
FRANCIS, FRANK	BENEFIT ADVISOR	17335667	YES		12/30/15
FRANCONE, SHELLY	BENEFIT ADVISOR	17045344	YES		12/30/15
FRAZIER, DOUGLAS	BENEFIT ADVISOR	17589144	YES		12/30/15
FREDERICK, NANCY	BENEFIT ADVISOR	1417521	YES		12/30/15
FREELAND, ANDRE	BENEFIT ADVISOR	17324272	YES		12/30/15
FREES, DAVID	BENEFIT ADVISOR	17683513	YES		12/30/15

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