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 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
STEPHANIE JONES	BENEFIT ADVISOR	17640066	YES		6/30/2016
TUKEVIA JONES	BENEFIT ADVISOR	17576489	YES		6/30/2016
ANNETTE KAMBARAMI	BENEFIT ADVISOR	17335675	YES		6/30/2016
SHEMEKA KENNEYBREW	BENEFIT ADVISOR	17710937	YES		6/30/2016
THOMPSON KERMAH	BENEFIT ADVISOR	13209812	YES		6/30/2016
NATHAN KING	BENEFIT ADVISOR	2073460	YES		6/30/2016
LINDA KULASIK	BENEFIT ADVISOR	16762935	YES		6/30/2016
KIMMESHA LEE	BENEFIT ADVISOR	17613007	YES		6/30/2016
NATASKIA LEE	BENEFIT ADVISOR	17624576	YES		6/30/2016
LAWRENCE LEVINE	BENEFIT ADVISOR	17072240	YES		6/30/2016
CHIKEYTA LEWIS	BENEFIT ADVISOR	17703703	YES		6/30/2016
SHARI LOCKE	BENEFIT ADVISOR	17332313	YES		6/30/2016
ASKI LOCKETT	BENEFIT ADVISOR	17692232	YES		6/30/2016
JESSICA LOGAN	BENEFIT ADVISOR	17332412	YES		6/30/2016
CARMA LOGIE	BENEFIT ADVISOR	17063654	YES		6/30/2016

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