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
CHASSITY LEE	AGENT	18030310		YES	12/28/2016
KEMIA LEE	AGENT	17692134		YES	12/28/2016
KIMMESHA LEE	AGENT	17613007		YES	12/28/2016
LACANDINCE LEWIS	AGENT	18088532		YES	12/28/2016
ERLINE LINDBERG	AGENT	15552944		YES	12/28/2016
SHARI LOCKE	AGENT	17332313		YES	12/28/2016
ASHLEY LOCKRIDGE	AGENT	18110144		YES	12/28/2016
AMELIA LOUD	AGENT	18034868		YES	12/28/2016
REKKIAH LOUDEN	AGENT	17555508		YES	12/28/2016
STEPHANIE LUCAS	AGENT	17335659		YES	12/28/2016
CHRISTOPHER MACE	AGENT	18045427		YES	12/28/2016
NORMAN MACMANN	AGENT	17015409		YES	12/28/2016
CECILY MALONE	AGENT	17658040		YES	12/28/2016
SYLVIA MALONE	AGENT	17685860		YES	12/28/2016
SHERYL MARINA	AGENT	17673858		YES	12/28/2016

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:	801-415-0579
Email Address:	LAC@EXTENDHEALTH.COM