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
ROSS, KAREN	BENEFIT ADVISOR	17349886	YES		12/21/2015
ROTH, BETTY	BENEFIT ADVISOR	16730575	YES		12/21/2015
ROTH, WILLIAM	BENEFIT ADVISOR	17015103	YES		12/21/2015
ROTHSCHILD, LOUISE	BENEFIT ADVISOR	17641162	YES		12/21/2015
ROUNDY, GLEN	BENEFIT ADVISOR	17627918	YES		12/21/2015
RUBIO, AUGUSTIN	BENEFIT ADVISOR	17384749	YES		12/21/2015
RUEDA, MONICA	BENEFIT ADVISOR	17328155	YES		12/21/2015
RUEDA, REYNA	BENEFIT ADVISOR	17048115	YES		12/21/2015
RUIZ, RUTH	BENEFIT ADVISOR	17692144	YES		12/21/2015
RULE, ALEXANDER	BENEFIT ADVISOR	15961220	YES		12/21/2015
RUSSELL, SHERRY	BENEFIT ADVISOR	1247840	YES		12/21/2015
RUSSELL, STEPHEN	BENEFIT ADVISOR	16616558	YES		12/21/2015
SALOHA, RANI	BENEFIT ADVISOR	15961214	YES		12/21/2015
SALVESEN, NANCY	BENEFIT ADVISOR	16268439	YES		12/21/2015
SAMPSON, VALENESE	BENEFIT ADVISOR	17590019	YES		12/21/2015

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