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
DAVID GORDON	BENEFIT ADVISOR	789864	YES		6/30/2016
MARTIN GRANADOS	BENEFIT ADVISOR	17358721	YES		6/30/2016
CHRISTOPHER GRANT	BENEFIT ADVISOR	17709989	YES		6/30/2016
SHENETTE GRAY	BENEFIT ADVISOR	17685795	YES		6/30/2016
KAYLA GREAM	BENEFIT ADVISOR	17663688	YES		6/30/2016
SCHMEKA GREEN	BENEFIT ADVISOR	17608387	YES		6/30/2016
MARIA GUTIERREZ	BENEFIT ADVISOR	8982628	YES		6/30/2016
KENDALL HAMAR	BENEFIT ADVISOR	1771075	YES		6/30/2016
YOLUNDA HAMILTON	BENEFIT ADVISOR	17374510	YES		6/30/2016
LECRESHIA HARDIN	BENEFIT ADVISOR	17355382	YES		6/30/2016
PATRICIA HASENYAGER	BENEFIT ADVISOR	15763864	YES		6/30/2016
KIMBERLY HEROD	BENEFIT ADVISOR	17078330	YES		6/30/2016
TONI HICKS DAVIS	BENEFIT ADVISOR	17522711	YES		6/30/2016
MALCOLM HIMES	BENEFIT ADVISOR	17710022	YES		6/30/2016
RAJEEYAH HINES	BENEFIT ADVISOR	17371941	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