Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	10975 S STERLING VIEW DR, STE A1
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	801-415-0579
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	10975 S STERLING VIEW DR, STE A1
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
GREGORY GOODWIN	AGENT	18083942	YES		09/22/2016
SHARATAZIA GRANT	AGENT	18084012	YES		09/22/2016
BELINDA GREEN	AGENT	18016395	YES		09/22/2016
CHELSEA GREEN	AGENT	18059248	YES		09/22/2016
SCHMYRA GREEN	AGENT	18048353	YES		09/22/2016
SOPHIA GREEN	AGENT	18095024	YES		09/22/2016
DES JANAE GREER	AGENT	18037245	YES		09/22/2016
DOMINIQUE GREER	AGENT	18030292	YES		09/22/2016
SHEILA GROVES	AGENT	18058478	YES		09/22/2016
MORGAN HAMILTON	AGENT	18103627	YES		09/22/2016
YVONNE HARRAL	AGENT	6968380	YES		09/22/2016
LIZETH HERNANDEZ	AGENT	18069920	YES		09/22/2016
BEATRIZ HINOJOSA	AGENT	18062210	YES		09/22/2016
AUDREY HIPPS	AGENT	17027541	YES		09/22/2016
SHERIDAN HOBDY	AGENT	16680655	YES		09/22/2016

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 & CHIEF TECHNOLOGY OFFICER
Phone Number:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM