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
CHENELL SAMUELS	AGENT	17683467		YES	12/29/2016
NOEMI SANCHEZ	AGENT	17358783		YES	12/29/2016
ISABEL SANDLER	AGENT	17354209		YES	12/29/2016
RICHARD SCHERBA	AGENT	1246419		YES	12/29/2016
MARY SCHUH	AGENT	11980666		YES	12/29/2016
MARNEE SCHULLER	AGENT	9548346		YES	12/29/2016
MARKIESIA SCOTT	AGENT	17147006		YES	12/29/2016
SHAUNTE SCOTT	AGENT	17697440		YES	12/29/2016
ZAKIYYA SCOTT	AGENT	17685877		YES	12/29/2016
LAUREN SEXTON	AGENT	18088637		YES	12/29/2016
BARRY SHAW	AGENT	17080124		YES	12/29/2016
REBECCA SHAW	AGENT	17601698		YES	12/29/2016
DANIELLE SHEPARD	AGENT	17683408		YES	12/29/2016
TAMARA SHIELDS	AGENT	17341687		YES	12/29/2016
PAULINE SHOEMAKER	AGENT	16730565		YES	12/29/2016

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:	801-415-0579
Email Address:	LAC@EXTENDHEALTH.COM