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 DRIVE, STE A1
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	18014150579
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	10975 S STERLING VIEW DRIVE, 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
SHAMEIKA OVERTON	AGENT	18048347	YES		8/21/2018
CRISTAL OCEJO	AGENT	18807424	YES		8/21/2018
LUJUANA NORRIS	AGENT	18816612	YES		8/21/2018
JOSEPH POE	AGENT	17597012	YES		8/21/2018
OCTAVIA CHAMBERS	AGENT	18048372	YES		8/21/2018
ALEX VALLADARES	AGENT	18862548	YES		8/21/2018
AYLA WASHINGTON	AGENT	18861032	YES		8/21/2018
ANDREW STUCK	AGENT	18852295	YES		8/21/2018
JOSHUA SWINTON	AGENT	17384579	YES		8/21/2018
NICOLE SEALY	AGENT	17204955	YES		8/21/2018
CHERYL VYFHUIS	AGENT	18510162	YES		8/21/2018
CRAIG STEELE	AGENT	18804859	YES		8/21/2018
DAN WEAVER	AGENT	8794038	YES		8/21/2018
STACIA ERKENBRACK	AGENT	18777422	YES		8/21/2018
FATIMAH MALONE	AGENT	17087413	YES		8/21/2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DAVID FEIL

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@WILLISTOWERSWATSON.COM