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:	8014150579
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
KHALILAH BROWN	BENEFIT ADVISOR	17673795	YES		5/19/2016
RAYVEN BUCHANAN	BENEFIT ADVISOR	17696217	YES		5/19/2016
MARLENE BULLARD	BENEFIT ADVISOR	15837468	YES		5/19/2016
SUZANNE BUSS	BENEFIT ADVISOR	17071169	YES		5/19/2016
KIMBERLY BUTLER	BENEFIT ADVISOR	17021121	YES		5/19/2016
TRENTON BUTLER	BENEFIT ADVISOR	17708032	YES		5/19/2016
ADA CARROLL	BENEFIT ADVISOR	17021623	YES		5/19/2016
CHYNNA CARTER	BENEFIT ADVISOR	17037111	YES		5/19/2016
PHOEBE CARTER	BENEFIT ADVISOR	16291886	YES		5/19/2016
SHAKIRA CARTER	BENEFIT ADVISOR	16819082	YES		5/19/2016
ERICA CHOICE	BENEFIT ADVISOR	17063187	YES		5/19/2016
DEVIN CLARKSON	BENEFIT ADVISOR	17063281	YES		5/19/2016
JOSHUA COLE	BENEFIT ADVISOR	17059901	YES		5/19/2016
BOBBIE COLLIER	BENEFIT ADVISOR	16521222	YES		5/19/2016
ELLORA CONERLY	BENEFIT ADVISOR	17328268	YES		5/19/2016

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