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
KATINA BENNETT	BENEFIT ADVISOR	17673843	YES		6/30/2016
STEVEN BIASATTI	BENEFIT ADVISOR	14910480	YES		6/30/2016
CHERICA BIVENS	BENEFIT ADVISOR	17683309	YES		6/30/2016
FLOYD BLACK	BENEFIT ADVISOR	16864898	YES		6/30/2016
NOWE BOLTON	BENEFIT ADVISOR	17332224	YES		6/30/2016
STEPHEN BOX	BENEFIT ADVISOR	16865191	YES		6/30/2016
DENAI BOYCE	BENEFIT ADVISOR	17615825	YES		6/30/2016
BRITTANIE BOYD	BENEFIT ADVISOR	17097482	YES		6/30/2016
TINA BRASHER	BENEFIT ADVISOR	17078439	YES		6/30/2016
STEPHANIE BRIMAGE	BENEFIT ADVISOR	8536781	YES		6/30/2016
DAVID BURNS	BENEFIT ADVISOR	1210084	YES		6/30/2016
CRESHAWNDRA CALDWELL	BENEFIT ADVISOR	17580724	YES		6/30/2016
DEBRA CALLAWAY	BENEFIT ADVISOR	664037	YES		6/30/2016
CHRISTINA CARTER	BENEFIT ADVISOR	17658269	YES		6/30/2016
COLLITTA CARTER	BENEFIT ADVISOR	17719802	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