Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
NPN:	8415824
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	10975 S. STERLING VIEW DRIVE
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
SARINANA, SYLVIA	BENEFIT ADVISOR	11550414		YES	12/31/15
SERRANO, RAUL	BENEFIT ADVISOR	11029467		YES	12/31/15
SHERRILL, TONYA	BENEFIT ADVISOR	11529952		YES	12/31/15
SIMS, JOHN	BENEFIT ADVISOR	7064571		YES	12/31/15
SLAUGHTER, STEPHANI	BENEFIT ADVISOR	7898485		YES	12/31/15
SMITH, ANNETTE	BENEFIT ADVISOR	800992		YES	12/31/15
SAURMAN, WENDY	BENEFIT ADVISOR	11548391		YES	12/31/15
SWAPP, RYAN	BENEFIT ADVISOR	7625313		YES	12/31/15
SWARTZ, CHAD	BENEFIT ADVISOR	799339		YES	12/31/15
TAYLOR, GARY	BENEFIT ADVISOR	5449945		YES	12/31/15
THOMAS, MARK	BENEFIT ADVISOR	9524438		YES	12/31/15
TOLLEY, ALAN	BENEFIT ADVISOR	9913310		YES	12/31/15
TRAVIS, DAVID	BENEFIT ADVISOR	11739976		YES	12/31/15
TRONCALLI, SAMUEL	BENEFIT ADVISOR	563324		YES	12/31/15
VAHSHOLTZ, RANDAL	BENEFIT ADVISOR	2231571		YES	12/31/15

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 AND CHIEF TECHNOLOGY OFFICER
Phone Number:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM