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:	801-415-0579
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
HILTON ADOLINAMA	AGENT	17539063		YES	10/25/2016
MICHAEL AKPOGUMA	AGENT	17658132		YES	10/25/2016
KAMWANNA BAKER	AGENT	18060644		YES	10/25/2016
MICHAEL BEKELE	AGENT	18034894		YES	10/25/2016
CHERICA BIVENS	AGENT	17683309		YES	10/25/2016
RACHEL BLYTHE	AGENT	18084008		YES	10/25/2016
JASMINE BOYD	AGENT	18082207		YES	10/25/2016
ZEE BROWN	AGENT	17703822		YES	10/25/2016
ALLEN BURGESS	AGENT	34942		YES	10/25/2016
CRESHAWNDRA CALDWELL	AGENT	17580724		YES	10/25/2016
EFFIE CLEWIS	AGENT	17048229		YES	10/25/2016
KRISTI CRAVEN	AGENT	17030053		YES	10/25/2016
INGRID DANCER	AGENT	17703700		YES	10/25/2016
SANDRA DAWSON	AGENT	8356081		YES	10/25/2016
BARBARA DEATON	AGENT	1232641		YES	10/25/2016

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