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
TAWYONA JONES	AGENT	18048324		YES	12/28/2016
TEVORIS JONES	AGENT	18059278		YES	12/28/2016
TUKEVIA JONES	AGENT	17576489		YES	12/28/2016
JAHCORYAN JOSEPH	AGENT	18030381		YES	12/28/2016
ANNETTE KAMBARAMI	AGENT	17335675		YES	12/28/2016
NANCI KASSEL	AGENT	16442414		YES	12/28/2016
CECILIA KING	AGENT	17410254		YES	12/28/2016
ALLEN KIRABO	AGENT	17670483		YES	12/28/2016
RICHARD KOSGEI	AGENT	17328384		YES	12/28/2016
TIERRA LACY	AGENT	18083947		YES	12/28/2016
NIKAYLA LAKES	AGENT	18048300		YES	12/28/2016
SHA RAYVIOUS LAMPKIN	AGENT	18095087		YES	12/28/2016
DEEBONI LANE	AGENT	18088654		YES	12/28/2016
MONIQUE LARY	AGENT	18095023		YES	12/28/2016
ONGEL LATIMORE	AGENT	17328432		YES	12/28/2016

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