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
HEIN, CAMILLE	BENEFIT ADVISOR	11739971		YES	12/31/15
HINCKLEY, JEFFREY	BENEFIT ADVISOR	769715		YES	12/31/15
HINES, CATHERINE	BENEFIT ADVISOR	804567		YES	12/31/15
HUNLOW, CHRISTOPHER	BENEFIT ADVISOR	11850260		YES	12/31/15
JENSON, MICHAEL	BENEFIT ADVISOR	14909879		YES	12/31/15
JOHNSON, RODNEY	BENEFIT ADVISOR	797762		YES	12/31/15
KELLEY, CHRISTOPHER	BENEFIT ADVISOR	7354907		YES	12/31/15
KRESTEL, CHRISTOPHER	BENEFIT ADVISOR	5442259		YES	12/31/15
LAMOUREU, MICHAEL	BENEFIT ADVISOR	9853001		YES	12/31/15
LEE, MICHAEL W	BENEFIT ADVISOR	7149845		YES	12/31/15
LOVETT-STARK, RUBY	BENEFIT ADVISOR	11519950		YES	12/31/15
MADDUX, ERIC	BENEFIT ADVISOR	13172373		YES	12/31/15
MARQUEZ, ESTHER	BENEFIT ADVISOR	11652833		YES	12/31/15
MARSHALL, SUSAN	BENEFIT ADVISOR	11565984		YES	12/31/15
MATTHEWS, SONIA	BENEFIT ADVISOR	11588720		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