Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND 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:	10975 S STERLING VIEW DRIVE, STE A1
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	10975 S STERLING VIEW DRIVE, 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
MUHAMMAD ABEDIN	BENEFIT ADVISOR	17658273	YES		5/19/2016
ELIZABETH AGEMERIEN	BENEFIT ADVISOR	17624699	YES		5/19/2016
MAUREEN AHERN	BENEFIT ADVISOR	17597823	YES		5/19/2016
FARAH ALFAR	BENEFIT ADVISOR	17655175	YES		5/19/2016
DALE BABBITT	BENEFIT ADVISOR	2884597	YES		5/19/2016
SHANNIQUE BANKS	BENEFIT ADVISOR	17328399	YES		5/19/2016
MARY BENNETT	BENEFIT ADVISOR	17097610	YES		5/19/2016
KEBIN BIKO	BENEFIT ADVISOR	17063304	YES		5/19/2016
DIANA BOLIN	BENEFIT ADVISOR	17048199	YES		5/19/2016
JACQUELINE BONNER	BENEFIT ADVISOR	17670520	YES		5/19/2016
LATOSHA BRADFORD	BENEFIT ADVISOR	17576501	YES		5/19/2016
JANAY BROOKS	BENEFIT ADVISOR	17608385	YES		5/19/2016
ARIELLA BROWN	BENEFIT ADVISOR	17655151	YES		5/19/2016
DANYELLE BROWN	BENEFIT ADVISOR	17685806	YES		5/19/2016
JASMINE BROWN	BENEFIT ADVISOR	17689217	YES		5/19/2016

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